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THE 


AMERICAN JOURNAL 


OF THE 

MEDICAL SCIENCES 


EDITED BY 

OEOEGE MOEEIS PIEESOL, M.E. 


NEW SERIES 

VOL. CXLVI 



PHILADELPHIA AND NEW YORK 

LEA & FEBIGEE 
1,913 




Entered according to the Act of Congress, in the year 1913, by 
LEA & FEBIGER 

in the Office of the Librarian of Congress. All rights reserved. 



CONTENTS OF VOI. CXLVI. 


ORIGINAL ARTICLES. 


The Occurrence of Anlde-clonus ■u’ithout Gross Disease of the Central 

Nervous System. By Wilder Tileston, M.D 1 

The Rational Treatment of Surgical or Non-pulmonary Tuberculosis. 

By John B. Hawes, 2d, M.D ' 10 

Myocardial Hydrothorax, with Reports of Cases. By James M. Anders, 

M.D., LL.D 15 

Congenital Atresia of the Duodenum. B 3 ’’ Archibald L. McDonald, 

A.B., M.D 2S 

Recoverj’’ from Tubercular Meningitis, with Report of Cases. By 

Robert L. Bitfield, M.D 37 

An Intensive Study of the Epidemiology of Pellagi’a. Report of Pro- 
Gress. By Joseph F. Siler, B.S., M.D., and Philip E. Garrison, 

A. B., M.D 42 

The Diagnosis of Inflammation in the Anterior Ocular Segment. Bj'' 

B. F. Baer, Jr., B.S., M.D 67 

Epididymitis Due to the Colon Bacillus. By Walter S. Reynolds, 

M.D. .' 72 

The Rational Treatment of Tetanus, with a Report of Twenty-three 
Cases from the Episcopal Hospital, Philadelphia. By Astlby 
Paston Cooper Ashherst, M.D., and Rutherford Lewis John, 

M.D. r . 77 

Isolated Sclerotic Involvement of the Mitral Valve. By Robert N. 

Willson, M.D 118 

Experiences with Steinmann’s Nail-extension Method in Fractures of 

the Femur. By John C. A. Gerster, M.D ' 157 

The Relations of Internal Secretion to Mental Conditions. By Pro- 
fessor Doctor L. V. Frankl Hochwart 186 

An Experimental Study of Sodium Bicarbonate and other Alhed Salts 
. in Shock. By M. G. Seelig, M.D., and J. Tierney and F. Roden- 
baugh 


195 



IV 


CONTENTS OP VOLTUIE CXLVI 


Pinching the Appendix in the Diagnosis of Chronic Appendicitis. By 

Anthony Bassler, AI.D 204 

The Effects of Continuous Administration of Extract of the Pituitary 

Gland. By John H. Mhsser, Jr., M.D 208 

Tuberculin Therapy in Surgical Tuberculosis, with the Correct Dosage 
Accurately Determined by the Cutaneous Reaction. By B. Z. 

Cashman, M.D 213 

The Influence on Gastric Secretion of Aseptic Foreign Bodies in the 

Gall-bladder. By 0. H. Perry Pepper, M.D 220 

Congenital Bilateral Fistulse of the Lower Lip. By L. Mieeer ICa.hn, 

M.D 223 

A Contribution to the Etiology of Pernicious Anemia. By Jaaees Taft 

Pilcher, M.D 226 

The Role of Hydrotherapy in the Treatment of Pellagra. By George M, 

Niles, M.D 230 

The Analogies of Pellagra and the Mosquito. By Stewart R. Roberts, 

S.M., M.D 233 

An Intensive Study of the Epidemiology of Pellagra. Report of Progress. 

By Joseph F. Siler, B.S., M.D., and Philip E. Garrison, A.B., 

M.D 238 

A Lobar Form of Bronchopneumonia of Long Duration, Occurring in 

Children and Young Adults. By Da\hd Riesman, M.D. . . . 313 

The True Value of Operation for Cancer. By Edward Milton Foote, 

M.D., 321 

Therapeutic Artiflcial Pneumothorax. By Herbert Maxon King, 

M.D., and Charles Wilson Mills, M.D 330 

The Diagnosis of Tuberculosis of the IQdney. By Floyd E.- ICeene, 

M.D., and John L. Laird, M.D 352 

Invagination of Meckel’s Diverticulum Associated with Intussuscep- 
tion; Report of a Case, with a Stud 3 ' of Recorded Cases. By 
Arthur E. Hbrtzler, M.D., and Edward T. Gibson, M.D. . 364 

Spinal Gliosis Occurring in Three Members of the Same Family, Sug- 
gesting a Familial Type. By George E. Price, M.D 386 

The Technique of Abderhalden’s Pregnancy Reaction. By Charles C. 

W. Judd, A.B., M.D 391 

Seven Cases of Cervical Rib, One Simulating Aneurysm. By N. Gilbert 

Seymour, A.B., M.D 396 

The Polyneuritic Foi'm of Acute Poliomyelitis; A Clinical and Patho- 
logic Studj'. By S. Leopold, M.D 406 



CONTENTS OF VOLUME CXLYI 


V 


■ An Intensive Study of Insects as a Possible Etiologic Factor in Pellagra. 

By Allan H. Jennings and W. V. King 411 

The Influence of Skeletal Defects, Congenital and Acquired, upon the 

Body in Health and Disease. By Chaeles F. Paintee, M.D. . . 469 

The Value of X-ray Examinations in the Diagnosis of Ulcer of the Stom- 
ach and Duodenum. By Julies Feeidenutali), M.D., and F. H. 

Baetjee, M.D 480 

The Present Situation in Syphilis. By William Allen Puset, A.M., 

M.D . 497 

The Heart in Sypliilis. By Haelout Bbooks, M.D 513 

Sjqihilis in the Etiology of Fibrous Osteitis, By P. G. Skillern, Je., 

M.D. . . . '. 631 

A Case of Sti*j'chnine Poisoning. By Albion Walter Hewlett, M.D. 536 
InsufEciency of the Pulmonary Valve. By Herman B. Allyn, M.D. . 541 

The Training of Students in Internal Medicine at German Universities. 


By Proeessor M. Matthes 552 

A Study of the Normal Coagulation of the Blood, with a Description of 

the Instrument Used. By George Morris Doerance, M.D. . . 562 


Chronic Ulcer of the Pylorus (Duodenal and Gastric) Secondary to 
Appendicitis, Colitis, Bile-tract Infection, and other Foci of Infec- 
tion udthin the Area Drained by the Portal Vein. By G. Paul La 

Roque, M.D 566 

The Clinical Features of Cases of Subacute Bacterial Endocarditis that 

Have Spontaneously Become Bacteria-Free. By E. Libman, M.D. 625 
The Noguchi Luetin Reaction in Syphilis. By George B. Foster, Jr., 

M.D 645 

Dorsal Percussion in Enlargements of the Tracheobronchial Glands. 

By John C. Da Costa, Jr., M.D 660 

The Transmissibility of the Lepra Bacillus by the Bed-bug (Cimex 
Lectularius L.). By Allen J. Smith, M.D., ICenneth M. Lynch, 

M.D., and Damaso Rivas, M.D 671 

Syringomyelia: with Autopsy Findings in Two Cases. By Oskar Klotz, 

M.D 681 

Modern Genito-m-inary Diagnosis and Treatment, with Reference Espe- 
cially to Laboratory Methods. By B. A. Thomas, A.M., M.D. . 696 

An Orthodiagraphic Study of a Case of Bronchial Asthma. By L. F. 

Warren, M.D • . . . 711 

A Contribution to the Study of Hereditary Degeneration (Pseudo-hyper- 
tropliic Muscular Dystrophy in Combination with Degeneration 
in the Central Nervous System). By Carl D. Camp, M.D. . . 716 



VI 


CONTENTS OP VOLUJIE CXLVI 


Two Instances of Chronic Family Jaundice. By Artuur H. Hopkins, 

M.D 726 

Clinical and Aletabolic Studies of a Case of Hypopituitarism Due to Cyst 
of the Hypophysis with Infantilism of the Lorain Tj’pe (so-called 
Tj^pus FroehUch or Adiposo-genital Dystrophy of Bartels). By 
De Witt Stetten, M.D,, and Jacob Rosenbloom, M.D., Ph.D. . 731 

The Diagnosis of Gastric Ulcer. By J. RussEnn Verbrtcke, Jr., AI.D. 742 
The Pathology of the ThjToid Gland in Exophthalmic Goiter. Bj’ 

Louis B. Wilson, AI.D 781 

The Clinical and Pathological Relationship of Simple and Exophthalmic 

Goiter. By H. S. Plomiier, M.D 790 

A Demonstration of a Depressor Substance in the Serum of the Blood of 
Patients Affected Rath Exophthalmic Goiter. By J. M. Blackford, 

AI.D., and A. H. Sanford, M.D 796 

Antitj^phoid Vaccination. By Frederick F. Russell, AI.D. . . . 803 

Cutaneous Alanifestations of Septicemia. By John W. CH 1 JRCH^LVN, 

AI.D 833 

Conclusions Derived from Further Experience in the Surgical Treatment 

of Bracliial Birth Palsy (Erb’s Type). By Alfred S. Taylor, M.D. 836 
Further Experiences with Stretching of the Pylorus. By Max Einhorn, 

xM.D 857 

Large-cell Splenomegaly (Gaucher's Disease) ; A Clinical and Pathological 

Study. Bj-^ N. E. Brill, M.D., and F. S M.\ndlebahm,AI.D. 863 

Aletallic Poisons and the Nervous System. By George A. Moleen, 

AI.D 883 

The Metabolism, Prevention, and Successful Treatment of Rheumatoid 

Arthritis; Second Contribution. By Ralph Pemberton, M.S., AI.D. 895 



CONTENTS OF VOLUME CXLVI 


YU 


REVIEWS. 


Reviews of Books 


124 , 278 , 441 , 587 , 747 , 906 


PROGRESS OF MEDICAL SCIENCES. 


Medicine 

Surgery 

Therapeutics .... 

Pediatrics 

Obstetrics .... 
Laryngology .... 
Gynecology .... 
Ophthalmology . 

Otology 

Dermatology .... 
Hygiene and Public Health 
Pathology and Bacteriology 


133 , 289 , 449 , 599 , 747 , 913 
137 , 294 , 453 , 603 , 761 , 915 
141 , 298 , 456 , 607 , 765 , 917 
. . . 144 , 301 , 768 , 919 

146 , 302 , 459 , 610 , 770 , 921 

151 , 926 

149 , 305 , 462 , 615 , 774 , 924 
. . . : . 776 

307 , 618 

464 

153 , 927 

310 , 466 , 621 , 779 




CONTENTS 


ORIGINAL ARTICLES 

The Occurrence of Ankle-clonus without Gross Disease of the Central 

Nervous System ^ 

By Wilder Tileston, M.D., Assistant Professor of Medicine, Yale 
University Medical School, New Haven, Connecticut. 

The national Treatment of Surgical or Non-pulmonary Tuberculosis 10 

By John B. Hawes, 2d, M.D., Director, TubercuHn Department, 
Assistant Visiting Physician, Massachusetts General Hospital; 
Secretary, Board of Trustees Massachusetts Hospitals for Con- 
sumptives. 


Myocardial Hydrothorax, with Reports of Cases 15 

By James M. Anders, M.D., LL.D., Professor of Medicine in the 
Medico-Chirurgical College of Philadelphia. 

Congenital Atresia of the Duodenum 28 

By Archibald L. McDonald, A.B., M.D., Attending Physician, 
to Children’s Home, Duluth, Minnesota. 

Recovery from Tubercular Meningitis, with Report of Cases .... 37 


By Robert L. Pitfield, M.D., Physician to St. Timothy’s and 
Germantown Hospitals, Philadelphia. 

An Intensive Study of the Epidemiology of Pellagra. Report of Progress 42 
By Joseph F. Siler, B.S., M.D., Captain, Medical Corps, United 
States Army, and Philip E. Garrison, A.B., M.D., Passed 
Assistant Surgeon, United States Navy. 

The Diagnosis of Inflammation in the Anterior Ocular Segment ... 67 

By B. F. Baer, Jr., B.S., M.D., Assistant Ophthalmic Surgeon, Eye 
Dispensary of the Hospital of the University of Pennsylvania, 
Philadelphia. 

Epididymitis Due to the Colon Bacillus 72 

By Walter S. Reynolds, M.D., Chief of the Clinic of Genito- 
urinary Surgery in the Medical Department of Columbia 
University, New York. 

The Rational Treatment of Tetanus, with a Report of Twenty-three Cases 

from the Episcopal Hospital, Philadelphia 77 

By Astley Paston Cooper Ashhurst, M.D., Instructor in Surgery 
in the University of Pennsylvania; Associate Surgeon to the 
Episcopal Hospital, etc., and Rutherford Lewis John, M.D., 
Resident Physician, Episcopal Hospital. 

Isolated Sclerotic Involvement of the Mitral Valve 118 

By Robert N. Willson, M.D., of Philadelphia. 

VOL. 146, NO. 1. ^JOLT, 1913 1 



11 


CONTENTS 


REVIEWS 

Progressive Medicine. A Quarterly Digest of Advances, Discoveries, and 
Improvements in the Medical and Surgical Sciences. Edited by 
Hobart Amory Hare, assisted by Leighton F. Appleman, M.D. . . 124 

Appendicitis. By John B. Denver, M.D., Sc.D., LL.D 125 

Augustus Charles Bernays. A Memoir. By Thekla Bernays .... 128 

The Pathology of the Living, and Other Essays. By B. G. A. Moynihan, 

M.S. (London), F.R.C.S 129 

Surgical Operations with Local Anesthesia. By Arthur E. Hertzler, M.D. 129 
On the Physiology of the Semicircular Canals and Tlieir Relation to Sea 

Sickness. By Joseph Byrne, A.M., M.D., LL.B 130 

The Surgical Treatment of Locomotor Ataxia. By L. N. Denslow, M.D. 131 
Handbook of Mental Examination Methods. By Shepherd Ivory Franz, 

Ph.D 132 

The Therapy of Syphilis. By Paul Mulzer, M.D. . . . . . . . 132 

PROGRESS OF MEDICAL SCIENCE 

MEDICINE 

UNDER THE CHARGE OF 

W. S. THAYER, M.D., and ROGER S. MORRIS, M.D. 

Alimentary Galactosuria in Experimental Phosphorus Poisoning . . 133 

The Bradycardia of Lead Colic 133 

Acetone and Diacetic Acid 134 

Syphilitic Aortitis 134 

■Congenital Family Steatorrhea 135 

On Uric Acid Excretion in Hj-pophyscal Disease 135 

Autoserotherapy and Absorption of Ascites 135 

On the Presence of Typhoid Bacilli in the Mouth of Typhoid Fever 

Patients and Typhoid Convalescents , 13G 

Blood Findings in Adiposity 136 

SURGERY 

UNDER THE CHARGE OF 

J. WILLIAM WHITE, M.D., and T, TURNER THOMAS, M.D. 

A Procedure for Wide Extirpation of Cancer of the Prostate . . . . 137 
Traumatic Epilepsy after Head Injuries in the Japanese-Russian War . 138 

Treatment of Spontaneous Gangrene of the Extremities 139 

Paralysis of the Plmenic Nerve from the Emploj’^ment of Kulenkampff’s 

Brachial Plexus Anesthesia 139 

The Extended Abdominal Radical Operation for Cancer of the Uterus . 140 



CONTENTS 


111 


THERAPEUTICS 

UNDER THE CHARGE OF 

SAMUEL W. LAMBERT, M.D. 

Syphilitic Disease of the Aorta 141 

Action of Benzol on Leukemia 141 

Treatment of Leukemia with Benzol 142 

Experiences with Neosalvarsan 142 

The End-results of the Abortive Treatment of Syphilis with Salvarsan . 142 

Cholesterin in Paroxysmal Hemoglobinuria 142 

The Treatment of Amebic Dysentery with Subcutaneous Injections of 

Emetin Hj^clrochloride 143 

Amebic Abscess of Liver Treated Successfully by Emetin 143 


PEDIATRICS 

UNDER THE CHARGE OF 

LOUIS STARR, M.D., and THOMPSON S. WESTCOTT, M.D 

Chronic Infective Endocarditis 144 

Diphtheritic Paralysis 145 

Summer Heat and Summer Diarrhea 146 


OBSTETRICS 

UNDER THE CHARGE OF 

EDWARD P. DAVIS, A.M., M.D. 

Albuminuria Likely to Recur in Successive Pregnancies 146 

Abderhalden’s Serum Test for Pregnancy 147 

Puerperal Eclampsia 147 

Unusual Fertility in Syphilitic Patients, with Anomalous Involvement 

of the Child 147 

The Condition of the Blood Serum of Mother and Fetus in the Pyelitis of 

Pregnancy 148 

Subcutaneous Symphysiotomy 148 


GYNECOLOGY 

UNDER THE CHARGE OF 

JOHN G. CLARK, M.D. 

Intestinal Obstruction Due to Retroverted Uterus 149 

Prognostic Value of Leulvocyte Count in Pelvic Suppurations . . . . 150 

Callous Ulcer of the Bladder 150 



IV 


CONTENTS 


DISEASES OF THE LARYNX AND CONTIGUOUS STRUCTURES 

UNDER THE CHARGE OF 

J. SOLIS-COHEN, M.D. 

Three Fatal Cases of PDeumococcal Infection of the Throat .... 151 

Abnormal Epistaphylian Tonsil 152 

A Case of Mixed Tumor of the Soft Palate 152 

Perforation of the Nasal Septum Due to Topical Action of Cocaine . . 152 

Chondrosarcoma of Nasal Passages 152 

Bronchial Astluna Cured by Operations in Rhinopharyngeal Respiratory 

Tract 152 

Topical Anesthesia in Sinus Operations 153 

I 

HYGIENE AND PUBLIC HEALTH 

UNDER THE CHARGE OF 

MILTON J. ROSENAU, M.D., and MARIC W. RICHARDSON, M.D. 

Chlorinated Lime in Sanitation 153 

The Stable Fly as a Carrier of Disease 154 

The Role of.the Stable Fly in the Transmission of Surra 156 



THE 


AMEEICAN JOURNAL 

OF THE MEDICAL SCIENCES 

JU'LY, 1913 

ORIGIN A.L ARTICLES 

THE OCCURRENCE OF ANKLE-CLONUS WITHOUT GROSS 
DISEASE OF THE CENTRAL NERVOUS SYSTEM. 

By Wilder Tileston, M.D., 

ASSISTANT PROFESSOR OF MEDICINE, TALE UNIVERSITY MEDICAL SCHOOL, 

NEW HAVEN, CONNECTICUT. 


For a long time ankle-clonus passed as one of the most certain 
signs of organic disease of the central nervous system, and some 
authors even asserted that it did not occur in the absence of such 
disease. In 1879, however, Strumpelh pointed out that clonus 
occurs with considerable frequency'' in consumptives, in severe cases 
of typhoid, and in emaciated, weak patients, without other signs 
pointing to disease of the nervous system, excepting hyperesthesia 
of the skin and muscles. 

It is the purpose of the present article to point out what condi- 
tions may be accompanied by ankle-clonus without other evidence 
suggestive of disease of the nervous system, to present a few illus- 
trative cases, including one in which an autopsy revealed slight 
microscopic changes in the medulla oblongata, and to discuss the 
importance of clonus in diagnosis and prognosis. This is desirable 
for the reason that the subject is not fully treated in the text-books 
of medicine and neurology. 

The Theory of Ankle-clonus. By ankle-clonus in this article is 
understood the true ankle-clonus, in which, on continuous upward 
pressure being made on the sole of the foot, there is a series of 
rhythmical oscillations in plantar flexion and extension, occurring 
with a frequency of from five to seven in the second, and continuing 
for a considerable period, often in fact so long as the pressure is 
maintained. Cases of so-called false clonus, in which a few irregular 


' Zur Kenntniss d. Sehnenreflexe, Deutsch. Arch. f. klin. Med., 1879, xxiv, 188. 
VOL. 146, NO. 1. ^JOLY, 1913 



2 tileston: the occurrence op ankle-clonus 

contractions take place, are not included. True ankle-clonus 
is never found in normal persons, and u^hen present is usualh^ 
associated with exaggeration of the tendon reflexes. It , is rarely 
present in cases showing increased tendon reflexes due to functional 
conditions (neurasthenia, etc.), but is frequently observed in or- 
ganic disease of the cord or brain, on which account it has been 
assigned considerable diagnostic importance. Clonus is also found, 
but less frequently, in other situations, especially the knee and 
jaw. In animals a closely analogous phenomenon is encountered 
in the so-called scratch reflex, so thoroughly studied by Sherring- 
ton.2 Here in response to a continuous electric stimulation of the 
skin a series of rhythmical movements of the leg takes place, 
having a frequency of four in a second. Absolute regularity of 
the contractions is present in both conditions, and has been shown 
in the case of the scratch reflex to be due to the presence of a 
refractory phase, during which stimulation fails to elicit a muscular 
contraction. The path of the reflex may be assumed to be from 
the sensorj’’ fibers in the gastrocnemius muscle to the lumbar cord, 
and thence back again to the muscle by its motor nerve. But 
the reflex is of course more complicated than this, involving co- 
incident inhibition of the antagonistic muscles, and a later contrac- 
tion of these muscles to bring the foot back to the original position. 
The close analogy with the scratch reflex, which has been shown 
to be a spinal reflex, makes it probable that the cerebral cortex 
is not directly concerned in the production of clonus. 

Anlde-chnm in Injections Diseases Without Gross Lesions of 
the Central Nervous Syste7n. In pulmonary tuberculosis, Striimpell, 
as already stated, was the first to note the presence of ankle-clonus. 
He found it of fairly frequent occurrence, especially in emaciated 
subjects. Longard^ seems to be the onl.y writer to have made an 
extensive study of the subject, finding it present in 30 of 82. tubercu- 
lous cases, but in only 7 of these was clonus associated with a general 
increase of the tendon reflexes. Six of these 7 were emaciated and 
febrile, the other was neither. In 8 cases clonus was noticed in 
well-nourished patients. He makes no mention of the stage of 
lung involvement, but from the fact that his cases were observed 
in a general hospital it may be assumed that they were in an ad- 
vanced stage. Personally I ha^m not met with clonus in incipient 
tuberculosis, but only in cases in the last stage. 

In typhoid fever the reflexes have been more thoroughly investi- 
gated, especially by the French. Remlinger'^ found ankle-clonus 
in 21 out of 100 cases, but in some of these the clonus was only 
“suggested.” In these 21 cases with clonus the tendon reflexes 
were increased in 16, normal in 2, diminished in 2, and absent in 1. 


* The Integrative Action of the Nervous Sj'slem, London, 1906. 
5 Deutsch. Zeitschr. f. Nervenheilk., 1891, i, 300. 

< Rev. de M6d., 1901, xxi, 46. 



tileston: the occurrence of ankle-clonus 3 

The plantar reflexes were normal in all. The period of the disease 
in which clonus was flrst noted was variable, the phenomenon 
occurring with about equal frequency in the early stage, at the 
height of the fever, and during defervescence. It is important to 
note that clonus was more frequent in the severe cases, indicating 
a high grade of toxemia, for the mortality in the cases with clonus 
was 28.6 per cent., almost three times that of the cases without 
clonus (10 per cent.). 

In other infectious diseases, such as septicemia (Case I of this 
paper), pneumonia, dysentery, cholera, malignant syphilis, the 
occasional presence of clonus has been noted, but no systematic 
studies have been made. 

The following cases observed by the writer will serve to illustrate 
the occurrence of clonus in infectious diseases. The first is of par- 
ticular interest because it is one of the few in which a postmortem 
examination of the central nervous system has been made. 

Case I. — Sex)tice7nia folloioing smtis thrombosis; marked clomis 
of ankle and jaw; autopsy; no meningitis nor gross lesions of central 
nervous system; moderate degenerative changes in pons and small 
foci of myelitis not involving pyramidal tracts. 

F. E., a female, aged fourteen years, entered the Massachusetts 
Charitable Eye and Ear Infirmary March 28, 1909, suffering from 
mastoiditis and sinus thrombosis, for which an operation was 
performed. There followed an intermittent fever, which continued 
until the death of the patient, April 15. When seen by the writer, 
April 12, there was marked emaciation, the head was retracted 
and stiff, and Ivernig’s sign was present. There was a marked 
and continuous clonus of the jaw and of both ankles, and the knee- 
jerks were increased. The plantar reflexes were normal, and there 
was no spgsticity of the legs. Lumbar puncture on two occasions 
yielded a clear fluid of normal pressure and sterile on cultures. On 
the fourteenth day the patient had fallen into a condition of stupor. 
The jaw clonus was less marked, and the ankle-clonus was present 
on the right side, but only suggested on the left. She died April 15. 
At the autopsy (Dr. Verhoeff) there was found suppurative mas- 
toiditis, with thrombosis of the lateral sinus at the site of operation, 
and intense venous congestion and edema of the cerebral pia- 
arachnoid, but no signs of meningitis; the spinal cord was not 
examined. There were septic endocarditis of the mitral valve and 
septic infarcts in the lungs, spleen, and kidneys. There was pus 
in both pleural cavities. From the spleen the streptococcus was 
obtained in pure culture. 

Microscopic Examination: Unfortunately only the medulla 
oblongata was available for microscopic study. For the notes the 
writer is indebted to Prof. E. E, Southard, of the Harvard Medical 
School: “The positive findings were two in number: (1) A 
generalized diffuse blackening of the fibers in the white matter 



4 tileston: the occurrence of ankle-clonus 

wherever examined, of a sort to suggest curable toxic changes rather 
than incurably destructive degeneration, and (2) foci of exudative 
myelitis, in general of an exceedingly mild character, but in one 
instance striking and associated with alterations in the nerve 
tissue itself. 

“To begin with the focal lesion, we find the meshes of the sheath 
of the posterior median artery in the posterior median septum 
densely filled with mononuclear cells, including a few pigment- 
bearing cells, a small but somewhat larger number of endothelial 
cells containing mononuclear cells, great numbers of lymphocytes, 
and a number of plasma cells. The endothelium of the posterior 
median artery had been largely stripped away and lost. One 
other small artery in the lateral segment of the bulb was found 
invested with a slender amount of exudate. The others, including 
the meningeal arteries were quite free from exudate. 

“There is no evidence of spread of exudate into the neighboring 
bulb tissue. The nerve cells of both nuclei of Goll do not staih 
properlj”-, but neither do anj'^ other nerve cells seen elsewhere look 
as nerve cells should.” 

Case II. — Severe typhoid fever in a girl, aged eight years; massive 
hemorrhages on twenty-fifth day, followed by marked ankle-clomis; 
direct transfusion of blood, with prompt improvement, and disappear- 
ance of ankle-clonus in five days. 

B. C., a female child, aged eight years, entered the New Haven 
Hospital September 7, 1910 (service of Dr. C. J. Bartlett), vnth 
typhoid fever. At entrance the knee-jerks were normal. The dis- 
ease ran a severe course, and on September 25, the twenty-fifth day 
of the disease, there were two profuse hemorrhages from the bowels. 

- \^Tien seen by the writer the next day the child appeared exsan- 
guinated, restless, dyspneic, and thirsty, but was conscious. There 
was marked and continuous ankle-clonus on both sides, the Achilles 
and patellar reflexes were greatly increased, but the Babinski 
and Oppenheim phenomena were both negative and the abdominal 
reflexes were normal. There was no spasticity. There were no 
signs of meningitis nor of other disease of the central nervous system. 
The same day the operation of direct transfusion of blood was 
performed, with immediate improvement in the alarming condition. 
The clonus persisted until October 1, when it disappeared and 
remained absent thereafter. Recovery was uneventful and 
complete. 

Case III. — Girl, aged fifteen years; in last stages of phthisis; 
ankle-clonus five days before death. 

E. K., Russian Jewess, entered the Channing Home for Con- 
sumptives October 4, 1903, and died October 9, 1903. Duration 
of s^^nptoms four months. Physical examination showed an 
emaciated girl, too weak to sit up. There were signs of extensive 
consolidation and a ca\dty on the right side, and of less extensive 



tileston: the occurrence of ankle-clonus 5 

involvement of the left lung. There was a typical ankle-clonus 
on the right side and a slight one on the left. The knee-jerks 
were increased; the sensation- Avas normal. 

Case IV. — Girl, aged seventeen years; in third stage of pJitJnsis; 
ankle-clonus six weeks before death. 

A. E. F., an Irish girl, entered the Channing Home for Con- 
sumptives August 31, 1903, with symptoms of three months’ dura- 
tion, and died November 29, 1903. She had lost fourteen pounds 
in weight, but was still fairly nourished. Temperature, 102°, 
pulse, 140. The process advanced rapidly, and in a month after 
admission there was complete consolidation of the right lung and 
of the left upper lobe. Tubercle bacilli were found in the sputum. 
Ankle-clonus was found on both sides, with marked exaggeration 
of the knee-jerks. Four days -later the clonus was well marked on 
the right side, but only slight on the left. 

Cases like the foregoing are not uncommon, but heretofore have 
not been generally recognized. It will be noticed that the clonus 
may be either one-sided or bilateral, and does not usually persist 
for more than a few days or weeks. In the writer’s experience 
clonus has been more frequent in the young and in the female 
sex, but this may be due to the nature of the clinical material. 

Ankle-clonus in Cachexia. Sternberg^ mentions clonus in weak, 
emaciated patients afflicted with malignant disease and “senile 
marasmus.” 

Ankle-clonus in Various Intoxications. In uremia ankle-clonus 
is not uncommon, and, as Curschmann® pointed out, may in chronic 
cases, come on several days before the uremic seizure, thus furnishing 
a valuable prognostic indication. Lion'^ also found a marked in- 
crease in the tendon reflexes, and sometimes ankle-clonus shortly 
before the uremic outbreak, though a moderate increase was not 
uncommon in chronic nephritis in the absence of uremic symptoms. 
With improvement or recovery he found a return of the reflexes 
to normal. 

During narcosis from ether and chloroform, Goldflam® found 
ankle-clonus frequently. Striimpell and Sternberg mention in- 
creased tendon reflexes in acute strychnine poisoning, but do not 
state whether clonus was present. Lewandowsky® states that 
Syllaba and Crocq noted clonus in chronic mercurial poisoning, 
but the writer was unable to find a reference to the original article. 
While chronic alcoholism increases the tendon reflexes it does not 
apparently give rise to clonus in the absence of organic changes. 

An interesting state of the reflexes is found after the use of 

5 Die Sehnenreflexe \i. ihre Bedeutung f. d. Pathologic des Nervensystems, Leipzig, 1893, 
pp. 95 to 97. 

® Verhandl. d. Kongress f. innere Med., 1909, xxvi, 341. 

’ Zeitschr. f. klin. Med., 1903, 1, 257. 

* Neurol. Centralblatt, 1903, xxii, 1109, 1137. 

• Handb. d. Neurologic, 1910, i=, 603. 



6 


tileston: the occurrence op ankle-clonus 


hyoscine (scopolamine) in medicinal doses. Ankle-clonus was 
noted in from one-quarter to one-half the cases by Hahn/® Kutner," 
and Link/2 ^nd more remarkable still there was a positive Babinski 
toe sign in a still greater proportion, up to 86 per cent. The 
Babinski sign appeared in about one-half hour after administra- 
tion, and after a minimum dose of 0.0004 gm. This production of 
a positive toe sign indicates a curious selective action on the part 
of hyoscine not to be found after the use of any other drug, and is 
one of the few exceptions to the rule that a positive Babinski, 
when found in adults, indicates organic- nervous disease. The 
tendon reflexes after hyoscine showed no consistent changes, and 
the muscle tonus was said to be diminished. 

Aiikh-clonm in Neuroses and Pyschoses. In epilepsy, according 
to Gowers,!® ankle-clonus is often to be found immediately after 
the convulsion, but only for a short time, and Babinski!'* has 
found his toe sign usually positive at this time. 

The occurrence of ankle-clonus in neurasthenia is denied by many 
authorities, but Oppenheim!® in his text-book states that it may be 
found, though rarely. Its presence should make one dissatisfied 
with the diagnosis of neurasthenia, for in most such cases some 
organic disease will be found. An instance in point is a case origi-- 
nally reported by Ballet!® as one of neurasthenia, with ankle-clonus, 
but shown by the autopsy some years later to have been syphilitic 
meningitis. 

In the case of hysteria there is also much difference of opinion. 
Most authorities are agreed that ankle-clonus does not occur in 
hysteria unless there is paralysis, and that it is absent in the com- 
mon flaccid type of paralysis. In the hysteric spastic paraplegia, 
with contracture, however, ankle-clonus has been described by 
many authors, chiefly of the German school. Oppenheim and 
von Monakow!! consider it rare, while Strumpefl!® g^yg jg often 
encountered in this form of paralysis. Babinski!® claims that when 
clonus is met with in hysteria it is always due to some extraneous 
factor, such as organic disease or excessive fatigue. The presence 
of ankle-clonus in hysteric subjects should therefore always arouse 
a suspicion of organic nervous disease, which becomes a certainty 
if the Babinski toe sign is present, for this is never met with in 
uncomplicated hysteria. 


10 Neurol, Centralblatt, 1911, xxx, 114, 185. 

11 Deutsch. med. "Woch., 1907, xxxiii, 98. 

12 Zeitschr. f. klin. Med., 190G, lix, 252. 

1* Epilepsy and Other Chronic Convulsive Diseases, London, 1901, 2d edit. 
1* Rev. neurologique, 1899, xii, 512, 

15 Lehrbuch d. Nervenkrankheiten, V Aufiage, 1908. 

15 Rev. neurologique, 1903, xi, 234; 1905, xiii, 732. 

11 Gehirnpathologie, II Auflage, 1905, p. 489. 

18 Lehrbuch d. spec. Path. u. Therap., XIII Auflage, Band iu, S. Glo. 

1* L’Enc^phale, Paris. 1909, ivi, 40. 



tileston: the occurrence of ankle-clonus 7 

In paralysis agitans, according to Oppenlieim, the tremor of the 
foot may simulate clonus, and very rarely a true clonus may be 
present. 

Bonhoeffer2“ and WestphaP^ have found transitory ankle-clonus, 
with spastic gait, in acute psychoses in the stage of excitement and 
loss of weight; Bonhoeffer speaks of his cases as psychosis with 
anxiety (“ Angstpsychosen”), without giving a more definite 
diagnosis. 

Ankle-clonxis in Arthritis. It is important to remember • that 
chronic disease of a joint often causes increased reflexes of the 
corresponding limb, and if the ankle is involved, ankle-clonus is 
by no means uncommon, apart from any organic nervous disease. 
In acute articular rheumatism clonus has not been reported, 
probably owing to the immobilization of the joints by muscle 
spasm. Jones^^ mentions the presence of jaw-clonus when the articu- 
lations of the jaw are involved. Clonus may occur in various 
types of chronic arthritis. Thus the writer has seen it in the gono- 
coccal and chronic infectious types, while Jones emphasizes it 
in rheumatoid arthritis. The mechanism of its production is not 
clear, but might be explained on the ground that frequent painful 
stimuli from the joint put the corrresponding segment of the cord 
into a state of overexcitability, so that the stimulation of the Achilles 
tendon results in clonus. 

Ankle-clonus after Fatigue. Several authors state that ankle- 
clonus may be found after unusual fatigue, or loss of sleep combined 
with anxiety, and Auerbach^^ found clonus in 2 out of 39 bicyclists 
after long distance (50 to 100 km.) races. After long-distance 
runs, however, the results are different, Knapp and Thomas^'’ 
and Oeconomakis^^ finding no instances of clonus, but rather a 
diminution of the tendon reflexes, after “Marathon” races of 42 km. 
The difference may be due, as Oeconomakis suggests, to the fact 
that the calf muscles are comparatively little used in bicycling, 
while in running there is a chance for the reflex arc to become 
exliausted. 

Graphic Studies of Ankle-clonus. The most extensive investi- 
gation of clonus by graphic methods has been made by Levi.^'^ 
He found that the clonus associated with organic disease showed 
in the tracing oscillations of equal height and equally spaced, 
while in the pseudoclonus found in functional diseases and in con- 
valescence from acute infections (only one case studied) the oscilla- 
tions were of unequal height, giving an irregular appearance to the 


2" Seitenstrangersoheinungen bei akuten Psychosen. Psychiatrische Abhandlungen herausgeg. 
V. C. Wernicke, Breslau, 1896, Heft ii, p. 1. 

Neurolog. Centralbl., 1903, xxii, 12 (foot-note). 22 Lancet, 1902, ii, 1746. 

Neiirolog. Centralbl., 1905, xxiv, 251. 

=* Jour. Nerv. and Ment. Dis., 1904, xxxi, 94. 

“ Neurol. Centralbl., 1907, xxvi, 498, 563. 

Arbeiten. a. d. Neurolog. Institut. a. d. Wiener Universilfit, 1907, xvP, 27. 



8 tileston: the occurrence of ankle-clonus 

curve. In one of liis cases, diagnosticated as hysteroneurasthenia, 
the clonus to the naked eye seemed to be genuine, and only the 
tracing proved it to be “false.” Levi claims that true clonus is 
always a sign of organic disease, provided that the graphic method 
has been employed. The string galvanometer of Einthoven has 
also been used by Salomonson*^ in the study of clonus, and he, too, 
found a perfectly regular curve in the case of organic disease, while 
hysteria showed, besides the action currents of the clonus, those of 
voluntary muscle tetanus. These methods appear to offer a valu- 
able way of studying clonus, but the observations have not been 
extended enough to be conclusive. It is desirable that further 
studies with them should be made in cases of ankle-clonus without 
organic disease of the nervous system. 

The State of the Skin and Tendon Reflexes. In the class of cases 
under consideration the skin reflexes maj’^ be increased or diminished, 
but Babinski’s toe sign is almost invariably absent, an important 
distinction from clonus due to organic disease, where it is usually 
to be elicited. The sole exceptions to this rule are clonus after 
the use of hyoscine and immediately after the epileptic convulsion, 
in both of which conditions a positive Babinski is the rule. The 
same holds true of Oppenheim’s sign. The tendon reflexes are 
usually but not always increased, when clonus is present, whether 
it, be due to organic or functional disease. 

Pathological Anatomy of Clonus Unassoeiated With Organic 
Disease, Up to the present but three cases have been studied 
anatomically, viz., those of Striimpelb^s Sternberg, and the writer’s 
first case. Striimpell’s case was one dying of phthisis, and the spinal 
cord was found normal, both macroscopically and microscopically. 
This, however, was in 1873, before the introduction of the finer 
stains for nervous tissue. Sternberg’s case was also one of phthisis, 
and the spinal cord is said to have been normal on microscopic 
examination, but no details are given. In the writer’s case foci 
of myelitis were found in the posterior columns in the bulb, as well 
as diffuse Marchi degenerations. Not too much stress should be 
laid on the latter, however, for Gay and Southard^® found such 
diffuse changes in a considerable proportion of cases dying of acute 
terminal infections. Further studies, including both brain and 
spinal cord, are necessary before the question of the absence of 
“organic” changes can be settled. 

Explanation of the Occurrence of Clonus in the Absence of Organic 
Nervous Changes. It will be remarked that practically all the 
conditions under discussion are accompanied by toxemia, usually 
of a serious ' nature. Even in the case of clonus after excessive 
fatigue there is reason to believe that toxic products are at work. 
It is possible that the deleterious substances affect only the function 

2' Folia neiiro-biol., 1010, iv, 1. 

25 Loc. cit. ” Foe. pit. 

Ccntralbl. f. Bakt., Parasitenkunde u Jnfeetionskrarik., 1910, Iv. 117. 



tileston: the occurrence op ankle-clonus 9 

of the nervous tissue, but it is also not improbable that there are 
structural changes, such as Edinger,®^ for instance, has shown to 
take place in rats after overexertion. Such changes, however, 
must be capable of complete recovery, for the clonus may disappear 
quicldy, not to return. We are still in doubt as to the exact way 
in which clonus is produced. If, with Oppenheim, we regard ankle- 
clonus simply as an exaggeration of the Achilles reflex, we might 
suppose that the toxic substances rendered the nerve fibers, or 
perhaps the synapse in the cord, more irritable. The phenomenon 
cannot be accounted for solely by the removal of cortical inhibition 
by reason of a lesion of the pyramidal tracts, for clonus is some- 
times found in cases of organic disease where these tracts are un- 
injured, and it may be lacking where they are completely degene- 
rated. The bulbar lesions in the writer’s first case are suggestive 
of the possibility that bulbospinal or bulbothalamal tracts might 
be of importance in the production of ankle-clonus. 

Diagnostic Considerations. The fact that ankle-clonus maj^ 
appear in so many and varied conditions of toxemia, quite apart 
from any demonstrable lesion of the central nervous system, 
makes it necessary to restrict the diagnostic importance heretofore 
attached to this sign. In the absence of these toxic states, however, 
it has still a great deal of practical value in the diagnosis of organic 
nervous disease. The probability of such disease is greatly enhanced 
if there is in addition to clonus a positive Babinski or Oppenlieim 
sign, as these do not occur in the toxic conditions under discussion, 
with the exception of hyoscine intoxication and the epileptic attack. 
The presence of a positive Mendel sign (plantar flexion of the toes 
on percussing the outer border of the foot over the fifth metatarsal 
bone), although considerably rarer than the other toe phenomena, 
appears to be conclusive evidence of organic disease. The complete 
absence of spasticity and of other signs pointing to organic lesions 
is also of importance in distinguishing the “functional,” or “toxic” 
cases. On account of the rarity of true clonus in uncomplicated 
neurasthenia and hysteria its presence should always arouse the 
suspicion of coexisting organic disease of the nervous system. 

Prognostic Value. In the infectious diseases the appearance of 
ankle-clonus certainly adds to the gravity of the prognosis, as it 
indicates a high degree of toxemia, but it does not preclude the pos- 
sibility of recovery. In nephritis it may be an important sign of 
the approaching uremic outbreak. The disappearance of the 
clonus is a favorable sign, except in the severest cases, where it may 
be only an indication of impending death. 

1. Summary and Conclusions. . Ankle-clonus indistinguish- 
able from the genuine may be found more or less frequently in a 
variety of conditions, without accompanying organic nervous 
disease. 


5' Verhandl d. Kongress f. inn. Med., 1898, xvi, 292. 



10 HAWES: TREATMENT OP NON-PULMONARY TUBERCULOSIS 

2. These conditions are: (a) Acute infectious diseases, especially 
tj^ihoid; (b) chronic infections associated with marked toxemia, 
especially tuberculosis of the lungs in the third stage; (c) uremia 
shortly before and during the acute uremic seizure; (d) epilepsy 
immediately after the convulsion; (e) intoxication from certain 
drugs, e. g., hyoscine, ether, and chloroform; (f) excessive fatigue; 
(g) exceptional cases of certain neuroses, viz., neurasthenia, hys- 
teria, paralysis agitans; (h) psychoses in the stage of excitement; 
(i) chronic articular rheumatism. 

3. With the exception of joint disease, a toxic action on the 
nervous system may be assumed in all these states as the under- 
lying factor in the production of clonus. This is obvious in the case 
of the infectious diseases and drug intoxications; in uremia, epilepsy, 
and undue fatigue the presence of toxic products of metabolism 
may be regarded as probable, though not yet demonstrated, and 
even in hysteria and neurasthenia the action of toxic products in 
severe cases cannot be excluded. 

4. In the case of articular rheumatism a constant spinal irrita- 
tion from the inflamed joint tissues is the probable cause. 

5. In two autopsies on cases of phthisis, with clonus, no changes 
were found in the central nervous system. In the writer’s case, 
however, inflammatory exudate was demonstrated about the pos- 
terior median artery in the posterior septum of the bulb. 

6. Clonus due to toxic states usually may be distinguished from 
that of organic nervous disease by the absence of spasticity and of 
other signs pointing to organic disease, and particularly by the 
absence of the Babinski and Oppenheim toe signs. 

7. An exception to the above rule is encountered after the use 
of hyoscine in medicinal doses and immediately after the epileptic 
attack, in both of which instances the Babinski and Oppenheim 
signs may be positive. 

8. The occurrence of ankle-clonus is of prognostic value in uremia, 
preceding at times the acute seizure. Ankle-clonus usually dis- 
appears a few days before death, otherwise its disappearance 
usually indicates an improvement in the patient’s condition. 


THE RATIONAL TREATMENT OF SURGICAL OR 
NON-PULMONARY TUBERCULOSIS. 

By John B. Hawes, 2d, M.D., 

DIRECTOR, TUBERCULIN DEPARTMENT, ASSISTANT VISITING PHYSICIAN, MASSACHUSETTS GENERAL 
hospital; SECRETARY, BOARD OF TRUSTEES MASSACHUSETTS HOSPITALS FOR CONSUMPTIVES. 

I DO not intend this article to be an argument against the proper 
use of surgery in surgical tuberculosis. I shall endeavor to show, 



HAWES: TREATMENT OF NON-PULMONARY TUBERCULOSIS 11 

however, that in the majority of cases of non-pulmonary tubercu- 
losis surgical interference is but an incident in a course of treatment 
the most important part of which comes before and after the opera- 
tion. In other words, in practically no case of surgical tuberculosis 
can the operator, no matter how sldlful, remove all traces of tuber- 
culosis; in tuberculous cervical adenitis, for instance, it is not 
uncommon to meet patients with large disfiguring scars in the 
neck and with a history of recurrence of the glands soon after the 
operation. These patients are recorded on the hospital records as 
“discharged cured.” Only too often subsequent events demon- 
strate the fallacy of this statement. 

During the past three or four years the attitude of many sur- 
geons has undergone a radical change as to the treatment of sur- 
gical tuberculosis. While there still remain certain cases in which 
extensive surgical procedures are indicated, such as in renal tuber- 
culosis, surgeons are coming to realize more and more that their 
duty to the patient does not end with the completion of the opera- 
tion and the discharge of the patient from the hospital; they are 
recognizing the fact that only by constant careful supervision for 
many months afterward can a permanent cure be obtained. Further 
than this they are learning that equally careful and constant 
supervision prior to any surgical procedure will vastly increase the 
benefits of any operation and in many cases do away with the need 
of it altogether. This paper is a description of the practical 
application of these principles as carried out in my clinic at the 
Massachusetts General Hospital. 

In July, 1905, Dr. Joseph H. Pratt, of Boston, started the first 
“tuberculosis class” in this country. This class consisted of a 
selected group of consumptive patients who were taught by means 
of weekly meetings and home supervision how to carry on what 
was known as “home sanatorium treatment.” At the start I 
became deeply interested in this movement, and soon formed 
such a class among my own patients. As time went on the number 
of beds for indigent consumptives in Massachusetts greatly in- 
creased, and thus the sphere of usefulness for tuberculosis classes 
became more and more limited until at the present time in this 
State one can assign to tlie tuberculosis class only a small part in 
the campaign against pulmonary tuberculosis. 

This is not the case with surgical tuberculosis, however. There 
are few_ beds for children and practically no beds for adults in 
sanatoria or hospitals in this State where patients with non-pul- 
monary surgical tuberculosis can receive adequate outdoor hygienic 
sanatorium treatment of which they are so badly in need. The 
reasons for this are obvious in that surgical tuberculosis is rarely 
a danger to the community which has its hands full in caring for 
its dangerous and infectious cases of consumption. These reasons, 
though perfectly adequate, render the case of the patient so un- 



12 HAWES: TKEATMEXT OF NON-PULIMONARY TUBERCULOSIS 

fortunate as to have tuberculosis of glands, kidney, etc;, instead 
of his lungs a very deplorable one. It became increasingly evident 
to me that while the usefulness of the home sanatorium movement 
must become less and less as far as consumption of the lungs was 
concerned, in surgical tuberculosis it was and mil continue to be 
a potent agent for good. 

The hospital authorities have seen fit to call this department 
which I have built up and devoted to the care of surgical tubercu- 
losis a “tuberculin clinic.” This is a misleading name. It is true 
that with the great majority of my patients I use tuberculin in 
conjimction with other measures, but in only a few cases would 
I be willing to attribute to tuberculin all or nearly all of the improve- 
ment which has usually taken place. In a certain class of patients 
with tuberculosis of the genito-urinary tract it has seemed to me 
that tuberculin is the most important factor in treatment; in the 
great majority of cases, however, it is undoubtedly a factor, but 
by no means the most important factor in producing good results. 
From the start I have confined myself to the use of a bouillon 
filtrate tuberculin kindly supplied me by Dr. E. R. Baldwin, 
of the Saranac Lake Laboratory. Other investigators have advo- 
cated the bacillary emulsion and certain other preparations, notably 
bowne tuberculin, hly results with the B. F. preparation have 
been so satisfactory that I see no reason for a change. 

Tubercuhn is administered once a week according to the well- 
Imown rules laid dovm by Trudeau. The initial dose is 0.0001 
to 0.0005 mg., rarelj' 0.001 mg. Tliis is graduallj’’ increased up to 
50 to 100 mg. Increase of dosage is gauged by careful observation 
of clinical signs of a reaction — ^local, focal, or constitutional. A 
few patients take their pulse and temperature regularly at home; 
in the majority of instances this is unnecessarjL Constitutional 
reactions have been exceedingly rare, and in no case has the slightest 
harm resulted from such occasional reactions while in not a few 
instances marked improvement seems to have followed a mild 
constitutional disturbance. It has been my aim to avoid all con- 
stitutional reaction by repeating the same dose or decreasing it. 
I have found it possible to carry most of my patients up to large 
amoimts of tuberculin without the slightest discomfort or disability. 

The elinic is held once a week at the out-patient department of 
the hlassachusetts General Hospital; the hospital prowdes me Buth 
a room, necessary equipment, and a nurse. Patients are referred 
to me from the other out-patient departments, particularly the 
male and female surgical and genito-urinary departments. Upon 
the arrival of any new patient, after a physical examination to 
rule out any pulmonary condition, a card is filled out recording 
temperature, pulse, and weight. The methods of treatment and 
reasons for ever 3 i;hing that is asked are explained in detail; the 
patient is then sent to the Social Sendee Department (without 
wliich or its equivalent no such clinic could exist) vdth the request: 



HAWES : TREATMENT OF NON-PULMONARY TUBERCULOSIS 13 

“Please investigate and report .to me as to home conditions.” 
This is followed by a personal interview with the social worker 
taking up the case, in which the exact needs of this individual 
patient are explained. The chief of the department from whom 
the patient was referred is also seen and his ideas obtained as to 
treatment of the local condition. In every case of tuberculous 
adenitis the patient is sent to the dental department for thorough 
cleaning of the teeth and to the throat department for tonsillectomy 
or other procedure if this is deemed advisable. All this takes time. 
It is often one or two weeks before all these important details can 
be attended to. At the outset every effort is made to secure the 
patient’s cooperation and to see that he or she understands the 
reason fpr everything. 

Patients begin to arrive shortly before 9 a.m. Men, women, 
and children are seen together in one large room. Each patient, 
on arrival, is given a numbered slip; temperature, pulse, and weight 
are recorded on the history cards, which are arranged in order at 
the table where I see the patients. One after another as I call 
out their names the patients come and talk over with me the de- 
tails of the past week. If the week has been an uneventful one, 
and the patient has had no signs of a reaction, constitutional or 
local, the interview is short; on the other hand, if the patient is 
not doing well, has lost weight, or is not following out directions it 
may take some time. Most of the patients I know well and call 
by their first names; they come to know each other and to enjoy 
the weekly meetings. I often call the attention of the entire group 
to striking points coming up in the course of my conversation with 
individual patients. Frequent consultations are held with the 
physicians and surgeons of other departments who are looking 
after the local conditions. The lungs are carefully watched, and 
whenever the slightest suspicion of pulmonarj'- involvement is 
found radical treatment usually in a sanatorium is instituted. 

Work vs. Rest. Many of these patients keep at their regular 
work during the entire course of active treatment. While it is 
advisable and necessary in the majority of instances that all work 
or sehool be given up at least for the first two or three months, in 
not a small number the general condition has been such that it 
has seemed a useless hardship to impose enforced idleness. 

Outdoor Sleeping. During the summer months many patients 
sleep outdoors; a few sleep out all the year round. The question 
of fresh air at night is carefully gone into in every case; and in 
many instances patients are allowed to go to school or to work on 
condition that they get a sufficient amount of fresh air at night. 

Length of Stay in the Clinic. Patients are urged to attend 
regularly once a week until the process is cured or arrested. This 
cannot be done in every case, and, as a general rule, a compromise 
has to be made. As the local process and general condition improve 
patients are frequently allowed to come once in two weeks instead 



14 HA\\'ES: TIJEAT-MEXT OF XOX-PDL:\IONAny TUBERCULOSIS 

of every week. When the disease is apparently arrested they report 
once a month or once in two months until a permanent cure is 
assured. 

Class of Cases. The greater number of patients in this clinic 
are those with tuberculous cer\ncal adenitis; in addition to this 
there are many cases of genito-urinar.y tuberculosis, tuberculosis 
of epididjunis, prostate, bladder, tubes, ureter, or. kidneys. Other 
less common cases are those with bone or joint disease, lupus, 
ocular, and mesenteric gland tuberculosis. 

Diet axd Drugs. If the patient is under weight one quart 
of milk a day in addition to the usual three meals is prescribed; 
occasionally olive oil in tablespoonful doses after meals is ordered. 
Unless the patients are distinctly in need of more nourishment 
nothing extra in the way of food is ordered, providing that it 
is definitely ascertained that three really good meals a day are 
assured. Drugs are rarel}' if ever used. 

Statistics axd Results. Since the time that this clinic has 
been devoted purely to extrapulmonary tuberculosis I have had 
209 patients under treatment and observation. Of these 209 
patients 50 are in regular attendance every week or every other 
week, and are therefore not included; 43 patients for one reason 
or another remained under treatment too short a time to allow 
of their being considered in this series. The chief causes of this too 
short a stay at the clinic were: 

(а) The presence of pulmonary tuberculosis which necessitated 
removal to a sanatorium as soon as possible. 

(б) The patient’s home was too far away to allow of regular 
attendance. 

(c) The home and financial situation were such that the patient 
was either unwilling or unable to attend regularly. 

This leaves 116 patients of whom I can speak with considerable 
certainty as to results. Each of these has been under more or less 
constant supervision, coming to report once a month or once in two 
or three months; the minimum period since attending regularly 
has been six months; in a large proportion of cases it has been two 
to four years since they were regular members of this department. 
These cases are dmded as follows: 


Tuberculous adenitis 60 

Ocular tuberculosis . . 2S 

Tuberculosis of kidney S 

Tuberculosis of epididj-mis 5 

Tuberculous tenosjTiovitis 3 

Bone tuberculosis 3 

Lupus 3 


Mesenteric gland tuberculosis . 
Tuberculous peritonitis . 
Tuberculous salpingitis . 
Tuberculous prostate 
Tuberculous fistula in ano . 



ANDERS: MYOCARDIAL HYDROTHORAX 


15 


I have used the terms adopted by the National Tuberculosis 
Association to denote results. This omits the term “apparently 
cured” substituting the more conservative one “disease arrested.” 
Of the 60 cases of tuberculous adenitis, which includes young and 
old patients, those with merely one small broken-down gland and 
those with extensive bilateral processes on which many operations 
had previously been performed with no permanent benefit, 46 
have had the disease arrested and are now well and heatlhy in 
every way, 13 have been markedly improved, while in onl3^ 2 in- 
stances has the disease progressed despite treatment. There have 
been no deaths. Of the 28 patients with ocular tuberculosis in 
some form 9 have had the disease arrested, 17 have been markedly 
improved, while in 2 cases the process has advanced. Of the 28 
remaining cases, which include various other forms of non-pul- 
monary tuberculosis, 14 have had their disease arrested, 12 have 
improved, while in 2 the disease has progressed. 

These results are by no means startling, although on the whole 
they are eminently satisfactory when one considers (1) the absolute 
lack of sanatorium facilities, (2) the comparative lack of adequate 
home supervision, and (3) the financial condition of most of these 
patients, which makes it necessary for by far the greater number 
of the adults to get to work much sooner than would have been the 
case under ideal conditions. 

As stated in the beginning of this paper, I do not attribute 
to tuberculin alone all or nearly all of whatever improvement 
has been brought about. It is a judicious combination of proper 
hygiene, conservative surgerjq and tuberculin backed up bj^ indi- 
vidualization in each case and the employment of applied common- 
sense that has helped these patients in the past and that will help 
similar patients in the future. 


MYOCARDIAL HYDROTHORAX, WITH REPORTS OF CASES. ^ 

By James M. Anders, M.D., LL.D., 

PliOFESSOK OP MEDICINE IN THE MEDICO-CHIIiDUGlCAL COLLEGE OP PHILADELPHIA. 

A COLLECTION of transuded serum in the pleural cavities is a 
secondary condition, most commonly associated with either cardiac 
or renal dropsy or the severe anemias, for example, leukemia and 
progressive pernicious anemia. Not infrequently, hydrothorax 
also supervenes in chronie dysentery, chronic diarrhea, carcinoma, 
syphilis, and scurvy. In all of the chronic diseases mentioned 

‘ Read before a stated meeting of the College of Physicians of Philadelphia, February 5, 1913. 



16 


ANDERS: MYOCARDIAL HYDROTHORAX 


the condition is in most cases, at least, a late development, often 
in the course of general dropsy, but such familiar examples are not 
included in the present discussion. It is also my purpose to exclude 
from consideration in this paper, hydrothorax dependent, upon 
local stasis due to new-growths of the pleura, lungs, and diaphragm. 

The renal group is a large one, and while the cases of hydrothorax 
that are secondary to chronic parenchymatous nephritis are not 
considered here, those that come on in the course of chronic inter- 
stitial neplu-itis are unilateral, as a rule, for longer or shorter 
periods of time, are caused by foregoing dilatation of the heart, 
and are included with the purely myocardial form. In the 
latter class both heart and kidney conditions are due to one and 
the same cause, namely, arteriosclerosis. It is readily conceded 
that in valvular heart affections attended with general venous 
engorgement the process may be unilateral for a time in con- 
sequence of local obstruction, but this group of cases is also elimi- 
nated from full consideration here, although reference will be 
made hereafter to its relative frequency as compared with myo- 
cardial hydrothorax. In short, this paper deals solely with instances 
of hydrothorax due to. myocardial disease, but with some of which 
chronic interstitial or atrophic nephritis was associated. 

The opinion commonly prevails among writers that in cachectic 
and renal cases, hydrothorax is usually bilateral. But though 
transudation is, in the majority of cases, bilateral, certain American 
authors, (Stengel, Osier, and Pepper) have insisted upon the view 
that it is sometimes unilateral throughout the whole or greater 
part of its course, for example, in the cardiac group of cases, 
which may be occasioned either by myocardial changes or chronic 
valvulitis, and when so is usually right-sided and may be unac- 
companied by e.xternal dropsy. 

Causes of Myocardl^ Hydrothorax. The association of 
cardiac disease and unilateral hydrothorax is not rare. This view 
is confirmed by the observations of Lord,^ who found in a series 
of fifteen cases that six were unilateral and right-sided, of which 
five' were complicated with heart lesions. It is a point of major 
significance that in myocardial disease the same mechanieal influ- 
ences are at work to bring about a pleural transudate as in valvular 
disease, principally cardiac dilatation, and more particularly of 
the right auricle. Moreover, the foregoing fact enables us to 
understand the reason for the election of the right side of the 
thorax as the seat of the serous transudate, in cases in which the 
condition originates primarily in sclerosis of the bloodvessels. 
Toxic poisoning of the myocardium or of the nerve centres is most 
probablj’^ also a causative factor of first-rate importance in the 
production of myocardial hydrothorax. 


* Osier’s Modern Medicine, iv, 848 



ANDERS: MYOCARDIAL HYDROTHORAX 17 

Again, cases of apparently incipient arteriosclerosis, so far as 
the peripheral bloodvessels are concerned, may show more marked 
changes in the small arteries that supply the viscera, the heart, 
and kidneys inclusive. This has been revealed by recent pathologic 
studies, and in such instances both the cardiac insufficiency on 
which the hydrothorax depends and also the urinary phenomena 
when present are produced by a more or less hidden arteriosclerosis. 

On reviewing the literature bearing upon the immediate causes 
of the cardiac variety of pleural transudate one finds that several 
recent theories have been advanced and ably championed. A 
considerable number of writers, among them Cardanelli, Villani, 
Howe, Lizzatto, and Pepper, attributed the occurrence of right- 
sided transudation of serum to an old pleural inflammation of 
low grade, which had so altered the perivascular tissue “that 
subsequently serous extravasation occurred with general venous 
stasis that had not become sufficient to cause external or bilateral 
pleural edema.” StengeP cites Villani and Peter as suggesting that 
irritations or inflammations of the liver may extend through the 
diaphragm to the pleura and thus occasion a combined pleural 
exudate and transudate. 

German writers have also called attention to this variety of the 
condition in many forms of liver and heart disease, including 
chronic myocarditis. These may show marked latency so far as 
general symptoms are concerned, to be followed after a variable 
length of time by edema of the legs, hepatic enlargement, and 
finally a left-sided transudate. 

More recently, competent observers have noted the occurrence 
not uncommonly of unilateral or right-sided hydrothorax inde- 
pendently of hepatic disease. Jaccoud first suggested pressure 
upon the azygos vein and superior vena cava as the cause. Stengel, 
who arrived at the same conclusion independently, argues from 
anatomic considerations, that is the relationship of the chest 
vessels to adjacent structures, that “even a moderate dilatation 
of the right auricle and cav^ must of necessity exercise consider- 
able compression upon the azygos vein and thus reduce its lumen.” 
Of course, similar conditions do not obtain on the left side of the 
chest. 

More recently still, Fetterolf and Landis^ have, as the result of 
their investigations, concluded that the serous fluid comes from 
the visceral and not from either the parietal pleura or azygos veins, 
the outpouring being caused, “so far as the pressure factor is con- 
cerned, by dilated portions of the heart pressing on and partly 
occluding the pulmonary veins.” They continue: “Greater fre- 
quency on the right side is due to the fact that dilatation of the 


“ Univ. Penn. Med. Bull., June, 1901. 

Ameb. Jour. Med. Sci., November. 1909. 



18 


ANDERS: jMYOCARDIAL iiydrothorax 


right auricle is'more common and more easy than a similar con- 
dition of the left side, and such dilatation is the only factor needed 
to cause damming back in the right pulmonary veins. On the 
left side, in order to include both upper and lower veins, there is 
needed dilatation of the left auricular appendix and of the left 
ventricle, with possibly a retrodisplacement of the vertical septum 
mentioned above, three factors as against one on the right side.” 
In 13 out of my 16 cases of the myocardial form the hydrothorax 
was wholly on the right side throughout. 

Incidence of Myocardial Hydrothorax. Of 27 cases of 
hydrothorax due to heart lesions that have fallen under my obser- 
vation, and of which I have clinical notes, not less than 16 (59 per 
cent.) were apparently caused by myocardial disease. In 5 of 
the 16 cases clear and convincing indications of well-pronounced 
chronic interstitial nephritis were coexistent. These were doubtless 
instances primarily of arteriosclerosis to which both the myocardial 
changes and the neplmitis were secondary. 

In 8 cases only slight evidences of arteriosclerosis coexisted, 
so that the probabilities are that either the myocardial degenerative 
and inflammatory lesions were primary or the changes in the blood- 
vessels of the heart and other viscera were decidedly more marked 
than in those that are accessible. In 9 cases, however (56 per cent.), 
the cardiac incompetency which led to the production of the hydro- 
thorax was caused by chronic myocarditis, as will appear evident 
hereafter. 

In none of the 16 cases were the clinical evidences of foregoing 
valvular sclerosis found. Of course, these figures are too small 
to base thereon safe inferences, and it is well known that 
individual experiences differ to a marked degree in relation to 
special conditions, yet there can be no room to doubt that hydro- 
thorax due to chronic myocarditis is more common than has been 
supposed. In this 'connection it is interesting to note that all of 
my cases occurred in males. 

Diagnosis of Myocardial Hydrothorax. Cases of myo- 
cardial hydrothorax are often characterized by extreme latency, 
particularly during the earlier portion of their course, the only 
subjective symptoms complained of being dyspnea especially on 
unwonted effort, and a dry, unproductive cough, which is not especi- 
ally annoying. This was true of most instances observed by me, 
although in all the signs and symptoms of chronic myocarditis, 
for example, cardiac dilatation, with hypertrophy, commonly 
hj’pertension, arrhythmia, dyspnea, and in 5 cases, as before 
stated, those of chronic interstitial neplmitis, were present. 

Obviouslj'’ a careful physical examination of the entire thorax 
would serve to enlighten the clinician, but is, according to my 
personal experience, often neglected because the hydrothorax 
which gives rise in a measure, at least, to the dyspnea and cough 



ANDERS: MYOCARDIAL IIYDROTHORAX 19 

is unsuspected. Moreover, my observation confirms the view that 
a serous collection of considerable magnitude in the right pleural 
sac may go unrecognized in the hands of a physician who is not 
fairly expert in the matter of physical examination. The physical 
signs are the same as those of pleurisy, with effusion, but, unlike 
the latter, serous collections are never encapsulated. 

Osler^ points out that postmortem records show how frequently 
the condition is overlooked. This fact is applicable in a special 
degree to the cases that arise in the course of ehronic myocardial 
changes after secondary dilatation supervenes, without external 
edema, and independently of valvular sclerosis. For example, in 
three of the five cases of hydrothorax which had not been recog- 
nized no external edema coexisted until late in the course of the 
condition. 

The principal error in diagnosis then, it has seemed to me, is 
in the assumption that hydrothorax is not to be expected in cases 
of cardiac disease in which the signs of chronic valvulitis and 
external edema are absent. Obviously, not all cases of arterio- 
sclerosis, with hypertension in which dyspnea whether on exertion 
or otherwise is present, are due to hydrothorax, since this is a 
striking feature of chronic myocarditis, as a rule, but if on close 
examination hydrothorax is found to be absent in this condition 
(chronic myocarditis) it should be recollected that, as pointed out 
by Janeway,® it indicates marked danger of cardiac insufficiency. 

Of the 16 instances of myocardial hydrothorax that have fallen 
under the writer’s observation not less than 5 had been unrecog- 
nized, the severe dyspnea having been attributed mainly, at least, 
to so-called cardiac or cardiorenal asthma and pulmonary con- 
gestion. The symptoms and physical signs, however, give a 
characteristic picture, although it is sometimes difficult to differ- 
entiate the cause, chronic myocarditis, from other underlying 
disease states in which hydrothorax supervenes. 

It is not uncommon to meet with cases of myocardial insufficiency 
that simulate closely those of valvular disease, particularly mitral 
incompetency, with which may be associated evidence of a mild 
grade of stenosis. There is, however, not obtainable a clear history 
of acute articular rheumatism in chronic myocarditis, but commonly 
of one of the exciting factors that may precipitate secondary dila- 
tation of the heart, such as physical or mental overstrain, an 
intercurrent febrile affection and the like. Moreover, the apical 
murmur has a more limited area of transmission in nonvalvular 
cases, and if the heart be “whipped up” by the use of cardiac 
stimulants it loses in intensity and may even disappear. 

It is said that, as a rule, transudation is not excessive, but in 


6 Text-book of Medicine, p. GG8. 

« Jour. Amer. Med. Assoc., December 14, 1012. 



20 ANDERS: MYOCARDIAL HYDROTHORAX 

two of my cases as much as 2000 c.c. of serum ivere removed on 
several oecasions, and in one case not less than 6500 c.c. were 
withdrawn at a single operation. In 15 out of the 16 cases of 
myocardial hydrothorax, tappings were earried out and no in- 
stances of mixed transudate and exudate were met with, although 
in one case of a right-sided transudate a left sided pleuritis with 
effusion was associated. While at first sight it may seem trite to 
suggest that more or less suspicious cases should be needled, there 
can be little doubt that this simple procedure, which gives us 
reliable information as to the existence and nature of the process, 
is not resorted to as regularly as it deserves to be. 

Course and Prognosis. While death is inevitable in by far the 
majority of cases, soon or late, even after marked improvement 
or apparent comfort has been brought about as the result of treat- 
ment, hydrothorax may develop, as my clinical records show at 
a comparatively early stage of arterial or myocardial disease with- 
out recurrence of the condition, if appropriately treated, and 
life prolonged indefinitely. Thus one of my cases has shown per- 
sistent good health for fifteen years following repeated aspirations, 
and the use of cardiac tonics and stimulants as well as other 
measures; another for a period of twenty months, and still others 
for shorter intervals of time. 

TreatiMENT. The treatment of this form of hydrothorax must 
have the same objects in view as in the other varieties, and has 
reference to the removal of the transudate by tapping the chest, 
and, so far as possible, of the causative condition by hygienic and 
medicinal means. It is futile, as a rule, to attempt to get rid of 
the transudate by the exliibition of digitalis and other cardiae 
stimulants without first withdrawing the fluid by aspiration if 
it be considerable in amount. I have repeatedly observed that 
this class of drugs only tends to aggravate the dyspnea without 
either diminishing the amount of the transudate or inereasing, to 
an appreciable extent, the urinary seeretion. 

On the other hand, after removing the fluid by means of thorac- 
entesis, eardiac stimulants often take hold and are of signal service 
in overcoming the dilatation of the heart and preventing a recur- 
rence of the transudate. The myocardial insufficiency in these 
cases demands a resort to remedies that will strengthen the heart 
muscle, for example, digitalis, strophanthus and the like, inde- 
pendently of an increased blood pressure, although nitroglycerin 
should be combined with these drugs if the arterial tension be 
deeidedly elevated. 

Rest is a most valuable adjunct in the treatment of the cardiac 
dilatation to which the hydrothorax is due; it must be, however, 
absolute and long continued. The use of saline laxatives carried 
to the point of rather active catharsis — three or four fluid evacu- 
ations daily — proved of decided serviee in a few of the cases. 



ANDERS: MYOCARDIAL HYDROTHORAX 


21 


In five instances of the series herewith reported a salt-poor diet 
was employed, with favorable effect, reaccumulation of the transu- 
date being thereby noticeably delayed. 

Brief notes of my series of cases are here appended : 

Case I. — Col. M. M. J., aged sixty-two years, occupation. 
Quartermaster U. S. A., consulted me March 25, 1898. 

Family previous and social histories negative. The present 
illness began in March, 1897, with symptoms of neurasthenia and 
indigestion. He later developed dyspnea and fatigue on effort, 
and, as his condition did not improve, he was referred to me by 
his physician. 

At my first examination I found the patient suffering from 
marked dyspnea, a moderate increase of blood pressure, with 
accentuation of second aortic sound, a dilated heart, and the 
physical signs of right-sided hj’^drothorax, the sac being about 
one-half filled. The urine contained an occasional trace of albumin 
and a few narrow hyaline casts; specific gravity, 1010 to 1015. 

Aspiration followed by complete rest for a period of two months 
and the use of cardiac stimulants and a non-nitrogenous diet 
caused the dyspnea and other symptoms to disappear. At the 
end of six months he again enjoyed good health, which persisted 
until one year ago, when he died of an acute illness. 

Case II. — F. L. M., male, aged fifty-seven years; occupation, 
general shipping agent. 

Family History. Negative. The patient was subject to tonsil- 
litis during adolescence; occasional mild attacks of rheumatism. 
Six years ago he was told by a physician that he had “kidney 
trouble,” was ill for one month. Habits good, excepting excessive 
use of tobacco. 

The present illness began six weeks ago, when the patient 
noticed dyspnea, palpitation, and loss of weight and strength. 
When I first saw him on March 17, 1908, there was evidence of 
marked arteriosclerosis, heart hypertrophied, second aortic sound 
much accentuated, and a moderate amount of free fluid in the 
left pleural sac, none in the right, and some edema of the feet 
and ankles. Examination of the urine: specific gravity, 1010; 
albumin, a small ring; casts, a few hyaline and finely granular; 
daily amount, 25 ounces. Blood pressure: systolic, 232 mm. 
Hg. On May 23 the left chest was aspirated and 17 ounces of 
fluid, having a specific gravity of 1014, were removed. The dyspnea 
was much improved. The patient left the hospital three days 
later and no subsequent report on his condition has been received. 

Case HI. ^H. L. J., male, aged forty-eight years; occupation, 
fireman, formerly miner. 

Family History . , Two brothers, a nephew, and a niece died of 
tuberculosis, otherwise negative. Habits: excessive use of coffee 
and alcohol for many years. 



22 ANDERS: MYOCARDIAL IIYDROTHORAX 

The patient first became indisposed on August 27, 1908, when 
he noticed some shortness of breath on exertion, which rapidly 
increased. When admitted to the Medico-Chirurgical Hospital 
on October 17, 1908, he complained severely of dyspnea, pain in 
the left chest, aggravated by breathing and by coughing; muco- 
purulent expectoration and occasional attacks of vomiting. The 
patient was cyanosed and an examination revealed an enormously 
hypertrophied and dilated heart, with weak, rapid pulse; no free 
fiuid in the chest, though numerous fine moist rales were audible 
over the bases of the lungs. There was marked edema of the feet 
and ankles. The urine showed a heavy ring of albumin and a 
few hyaline and finely granular casts. Systolic blood pressure, 
180 mm. Hg. No tubercle bacilli in sputum; numerous staphylo- 
cocci and streptococci present. On October 26 free fluid was noted 
in both pleural sacs, dyspnea increasing, while pain in the left 
chest had ceased. . Three days later the left chest was aspirated 
and 21 ounces of cloudy serum, having the characteristics of an 
exudate, were removed. Cultural studies revealed Streptococcus 
pyogenes. The following day th.e right chest was punctured and 
20 ounces of sterile fluid, having a specific gravity of 1014, were 
withdrawn. Following this operation the hydrothorax showed no 
tendency to reaccumulate. On the other hand, the left-sided 
pleurisy persisted and the exudate was removed on two other 
occasions before the death of the patient, on November 9, 1908. 

Summar}'- of the autopsy findings: Heart hypertrophied and 
much dilated, especially the right auricle; no fluid in right pleural 
sac which was normal in appearance; extensive left-sided empy- 
ema, with recent pleural adhesions; kidneys showed congestion and 
diffuse nephritis. 

Case IV. — A. E., male, aged forty-six years; occupation, police 
officer. 

' Family History. Father died of heart and kidney disease. 
Patient has consumed from 15 to 20 “whiskies” daily for the 
past eight years. 

The present illness began in November, 1908, with gradually 
increasing shortness of breath and marked edema of the legs. 
Under treatment the patient improved somewhat for a time, but 
soon after returning to his occupation there was a recurrence of 
the previous symptoms. When admitted to the Medico-Chirurgi :al , 
Hospital on January 6, 1910, there was edema of the legs extending 
half-way to the knees; some cyanosis and marked dyspnea. Heart 
markedly hypertrophied; second aortic sound accentuated; no 
murmur. At that time there was no fluid in the chest. Liver much 
enlarged; slight ascites. A faint trace of albumin, but no casts, 
was found in the urine. Blood pressure: systolic, 214 mm. Hg. 
During the stay of twelve weeks the patient showed much improve- 
ment, which continued until July 1911, when, following undue 



ANDERS: MYOCARDIAL IIYDROTHORAX 


23 


exertion, be had a recurrence of the foregoing symptoms. Again 
admitted on October 16, 1911, with signs of cardiac dilatation and 
right-sided hj'^drothorax. Following removal of this fluid the 
patient experienced much relief. Since then he has been aspirated 
at intervals of two months, during which time about 20 ounces 
accumulate. 

Case Y.— B. H. W., male, aged sixty-six years; occupation, 
manufacturer. Habits good, except for the immoderate use of 
alcoholic beverages. 

On November 30, 1908, the patient came to me complaining of 
vertigo, dyspnea on exertion, and dimness of vision. Physical 
examination revealed cardiac h 3 '^pertrophy and marked arterio- 
sclerosis. Systolic blood pressure, 225 mm. Hg. Ophthalmic 
examination showed iritis and a retinal hemorrhage near the 
macula. Urinalysis: albumin, small ring; casts, several narrow 
hyaline and finelj'^ granular. His condition remained about the 
same until September 5, 1909, when he was taken acutely ill with 
sj'^mptoms of cardiac failure, and renal insufficiency. Ten daj^s 
later free fluid was discovered in the right chest and a moderate 
amount of transuded serum was removed. This procedure resulted 
in much relief as to dyspnea, but the patient gradually sank into 
uremic coma and died three daj^s later. 

Case VI. — V. A. C., male, aged sixty-one j’-ears; occupation, 
railroad inspector. 

In December, 1906, I treated the patient in the Medico- 
Chirurgical Hospital for lobar pneumonia, which was followed 
bj'- circumscribed, right-sided empyema. After the removal of the 
exudate, the patient recovered and remained well until Januarj^, 
1910, when he began to complain of marked dyspnea, unproductive 
cough, and prostration. Upon his readmission to the hospital 
(March 5, 1910) I found the heart much dilated, blood pressure 
moderately elevated, Cheyne-Stokes breathing, cj^anosis without 
dropsy, and signs of free fluid in right pleural sac. UrinaU^sis 
revealed a trace of albumin and a small number of narrow hj^aline 
and finely granular casts. On March 15, 48 ounces of transudate 
were removed from the right chest; March 19, 46 ounces; March 
24, 32 ounces were withdrawn. The patient experienced much 
relief following each operation, but on March 27, he developed 
facial erysipelas, and died four days later. 

Case VII. — P. R., male, aged forty-two years; occupation, tailor. 
Moderate use of wines and tobacco; had gonorrhea fifteen years 
ago. 

The present illness began about July 1, 1910, with pain and 
swelling in right leg, which, however, did not incapacitate him for 
work until August 15. At this time he began to complain of diffi- 
culty in breathing, at times amounting to orthopnea, associated 
with cough and frothy expectoration. Vffien admitted to the 



24 


ANDERS: MYOCARDIAL IIYDROTHORAX 


Medico-Chirurgical Hospital on October 6, 1910, dyspnea was 
marked, moderate arteriosclerosis present, and the right lower 
extremity swollen and tender, otherwise no edema. • Physical 
examination showed signs of myocardial changes (dilatation) 
and right-sided hydrothorax. The transudate (18 ounces in amount) 
was withdrawn, but in spite of rest and vigorous cardiac stimu- 
lation the patient died suddenly three days later. 

Case VIII. — P. L., male, aged sixty-five jj^ears. Besides the usual 
infections of childhood the patient had acute articular rheumatism 
when aged twenty-eight years. 

The present illness began about October 19, 1910, when the 
patient first noticed dyspnea and palpitation on exertion. On 
March 16, 1911, these symptoms became more urgent. At this 
time the heart was dilated, second aortic sound slightly accent- 
uated; no murmur; pulse irregular; lower extremities edematous. 
Urinalj'^sis revealed a small ring of albumin and a moderate number 
of narrow hyaline and finely granular casts. Following rest in 
bed and cardiac stimulation the patient improved somewhat for 
a time, but early in June, 1911, the symptoms again became aggra- 
vated and a moderate right-sided hydrothorax was discovered. 
On June 15, 16 ounces of clear fluid, having a specific gravity of 
1010, were removed. Marked temporary relief followed this 
operation, but the fluid rapidly reaceumulated, and aspiration 
was again performed on June 22. Salt-free diet was now ordered 
and rapid diminution in the general edema followed, but the 
transudate in the chest reaccumulated, though more slowly. On 
July 3, 23 ounces were removed from the right chest, and from 
this time until the date of his death, August 1, 1911, the chest 
remained free from fluid. 

Case IX. — H. W., male, aged fifty-two years, admitted to the 
Medico-Chirurgical Hospital on June 15, 1911. Habits: rather 
excessive use of chewing tobacco and alcohol since early manhood. 

The present illness began suddenly six weeks ago, when he 
awakened one morning in a profuse perspiration and had to gasp 
for breath. Under treatment by his physician. Dr. J. D. Niles, 
he improved and felt comparatively well until one week since, 
when he was again seized with marked dyspnea and vertigo, 
which persisted. Four days ago he first noticed swelling of feet 
and legs. On admission I found the patient dyspneic, cyanosed, 
the heart moderately dilated, physical signs of right-sided pleural 
effusion, and a small amount of free fluid in the abdomen. Urine 
negative, except for low'^ specific gravity (1010); systolic blood 
pressure, 155 mm. Hg. The right chest was aspirated immediately 
and 10 ounces of transudate were removed. With rest in bed and 
the use of cardiac stimulants the patient continued to improve 
and left the hospital twelve days later apparently well. The 
patient so continued until late in July, when he had a recurrence. 



ANDERS: MYOCARDIAL HYDROTHORAX 


25 


and returned to the hospital, where it was found that the transudate 
had reaccumulated. The patient left the hospital ten days later 
in good condition, and there has been no recurrence of hydrothorax. 

Case X. — H. C., male, aged fifty-three years; occupation, 
liveryman. 

Family History. Father and brother died of dropsy. 

Previous History. Negative. 

The present illness began June 14, 1911, when, following unusual 
exercise, he noticed weakness and dyspnea. He entered the Medico- 
Chirurgical Hospital on July 3, at which time a physical examination 
revealed a dilated heart, an apical murmur, with a small area qf 
transmission, marked arrhythmia, many cardiac impulses, failing 
to reach the radial arteries. Liver somewhat enlarged. The 
urine showed a small ring of albumin and numerous hyaline casts; 
specific gravity, 1025. Systolic blood pressure, 106 mm. Hg. 

On July 11 there was some edema of ankles. Two days later 
signs of free fluid appeared in the right chest. This was removed 
a few days later, 25 ounces being obtained. The dyspnea was at 
once largely relieved. Following this there was gradual improve- 
ment in his condition, with disappearance of the murmur, and the 
fluid showed no tendency to reaccumulate. However, on July 29, 
the patient sat up in bed and suddenly fell over dead. 

Case XI. — M. D. J., male, aged fifty-six years. 

Family History. Rheumatism on maternal side. Had severe 
attack of influenza and rheumatism thirteen years ago; subject 
to digestive disturbances for many years. 

In February, 1910, the patient began to have attacks of angina 
pectoris. At that time the heart was hypertrophied, arteries 
markedly sclerotic; systolic blood pressure, 185 mm. Hg. Under 
treatment the angina attacks became less frequent and gradually 
ceased, and the patient enjoyed fairly good health until May 29, 
1911, when he began to complain of dyspnea and cough. 

Physical examination on June 22, 1911, showed cardiac dila- 
tation, arteriosclerosis, a moderate right-sided hydrothorax, and 
edema of the legs. Urinalysis revealed specific gravity, 1010; 
albumin, a small ring and casts, a moderate number of narrow 
and medium hyaline, finely and coarsely granular. As a result 
of prolonged rest in bed, salt-poor diet, purgation, and cardiac 
stimulation the fluid gradually disappeared, with marked improve- 
ment in his general condition. Since July, 1911, there has been 
no return of the hydrothorax, and the patient has remained free 
from symptoms. 

Case XII.— B. E., male, aged fifty-one years. Mother deceased 
of Bright's disease, and father of heart disease. Nine years ago 
had ureteral calculus (left-sided) removed. Moderate use of 
alcohol; tobacco to excess. 

The present illness began in October, 1910, with dyspnea, dry 



26 


ANDERS: ^MYOCARDIAL HYDROTHORAX 


cougli, but no edema,' as result of treatment he improved and felt 
well until three weeks ago, when, following undue exertion, the 
above symptoms recurred in an aggravated form. On November 7, 

1911, when I first saw him, there was much distress of breathing, 
heart dilated and h 3 Tiertrophied, some edema at bases of lungs 
and signs of right-sided pleural effusion without general dropsy; 
systolic pressure, 172 mm. Hg.; arteries palpable. Small albumin- 
uria and the presence of narrow hyaline and granular casts. 
Patient admitted to Medico-Chirurgical ^Hospital, where he 
remained five months at complete rest, with*the use of a salt-poor 
diet, saline laxatives, and cardiac stimulants. Heart stimulants, 
however, aggravated the dj^spnea until transudate had been 
removed. Later developed edema of legs. After six tappings the 
fluid failed to recur and external edema disappeared. Patient 
left the hospital on April 6, 1912, in fairl}^ good general condition. 
On Julj’’ 1 received statement from his home ph.vsician reporting 
a sudden recurrence of cardiac dilatation after too much exertion, 
proving rapidlj'^ fatal. 

Case XIII. — ^T. F. L., male, aged seventy-four j’-ears. The patient 
had acute articular rheumatism when aged thirty-nine years. 

The present illness began two j'^ears ago, when the patient first 
noticed arrhythmia associated with dyspnea on exertion. When 
first seen bj’’ me on December 24, 1911, there was orthopnea, legs 
slightly edematous, vessels decidelj’’ sclerotic, heart action irregular, 
heart dilated, a faint apical sj^stolic murmur, and marked right- 
sided hj^drothorax, which had been overlooked by the two attending 
ph.ysicians. Urinalj'^sis showed a faint trace of albumin and occa- 
sional hj-aline casts. Sj^stolic blood pressure, 118 mm. Hg. 

After the last of six tappings within three months the fluid 
showed no tendencj’^ to recur and the murmur had disappeared. 
During this period the patient was given a non-nitrogenous, salt- 
poor diet, purgatives, and cardiac stimulants. The patient gradu- 
alty improved and felt well until the last of June, 1912, when he 
had an apoplectic stroke, which proved fatal. 

Case XIV. — S. J., male, single, aged twenty-one j^ears; weight, 
135 pounds; height, 5 feet 8 inches; occupation, laborer. 

Family History. Negative. Five j^ears ago was squeezed between 
two railroad ears, sustaining some internal abdominal injuries. 
Habits good. 

Two- 3 'ears after the above-mentioned trauma was received, 
d^'spnea and abdominal distention appeared. February, 1912, 
the abdomen was tapped and 20 quarts (patient’s statement) 
of ascitic fluid removed. During the next three months para- 
centesis abdominis was performed tliree times. 

VTien admitted to the hledico-Chirurgical Hospital on June 22, 

1912, there was urgent dyspnea; c.yanosis and arrhj^thmia; large 
amount of free fluid in right chest; heart dilated; no murmur 



ANDERS : MYOCARDIAL HYDROTHORAX 


27 


audible; excessive ascites; liver enlarged; very slight edema of 
lower extremities. The urine was normal excepting the presence 
of a few hyaline casts. Blood pressure: systolic, 115; diastolic, 
100 mm. Hg. On June 24, 10 quarts of transudate were removed 
from the abdomen. The right chest was frequently aspirated 
and also the abdomen. Following each operation the patient 
was much relieved, but both the pleural and ascitic fluids showed 
a tendency to reaccumulate rapidljc Shortly before leaving the 
institution a small amount of fluid was discovered in the left 
pleural sac; this howcVer, was insufficient to necessitate aspiration. 
The patient left the hospital on August 7, 1912, and died three 
months later. 

Case XV.— J. L. J., male, married, aged sixty-four years; weight, 
144 pounds; height, 5 feet 8 inches; occupation, merchant. 

Family History. Negative. About eitht years ago had some 
pulmonary trouble; since then has been spending winters in 
Florida. Habits good, although he .worked hard under nervous 
tension. 

The present illness first manifested itself about two years ago, 
when slight dyspnea on exertion was noticed. Early in July, 1912, 
dyspnea became constant, and at times amounted to orthopnea. 
When I first saw the patient on July 12, 1912, his breathing was 
very labored and signs of moderate arteriosclerosis and cardiac 
dilatation were present. At the apex was heard a faint systolic 
whiff. Signs of bilateral hydrothorax, which had been overlooked, 
of considerable extent were elicited. At this time slight edema of 
the ankles was noted; later this became marked and extended to 
the hips. Urinalysis revealed a small ring of albumin, a moderate 
number of harrow hyaline and finely granular casts, specific gravity 
of 1022, and twenty-four-hour quantity, 20 ounces. Systolic blood 
pressure, 162; diastolic, 140 mm. Hg. 

The next day the patient was aspirated and 2 quarts of fluid 
were removed from each pleural sac. Reaccumulation however 
occurred, and the operation was repeated on August 3, 13, and 21, 
with a similar result. Following the last operation, absolute rest 
in bed was enjoined (owing to extreme nervousness and dyspnea 
this measure had not previously been practicable), and a salt-poor 
diet, cardiac stimulants, and saline laxatives were ordered. Under 
this treatment there was marked improvement; the edema of the 
legs rapidly disappeared and the chest remained practically free 
from fluid, and cardiac compensation was reestablished. After a rest 
in bed of two weeks the patient was permitted a limited amount 
of exercise; his favorable condition persisted until early in Novem- 
ber, when as a result of unwonted physical exertion there was a 
recurrence of the previous symptoms, with evidences of uremic 
intoxication superadded. Following the withdrawal of the pleural 
transudate and the institution of other therapeutic measures. 



28 MCDONALD; CONGENITAL ATRESIA OF THE DUODENUM 

improvement gradually ensued. The patient’s present condition 
is quite encouraging, although aspiration of the chest becomes 
necessary' at interv’^als of about three w'eeks. 

Case X^'I. — Y\'. G., male, aged fifty-nine years; weight, 190 
pounds; height, 5 feet 8 inches; occupation, shipper in brewery. 
Father deceased of heart disease; mother of kidney disease. 
Intemperate use of coffee, tobacco, and alcohol. 

Began about ten years ago, with dyspnea, at intervals palpi-, 
tation and headaches. On admission to hospital on August 13, 
1912, he showed a tendency to stupor, was dyspneic and cyanosed, 
heart dilated with relative mitral systolic murmur, second aortic 
sound accentuated. Signs of free fluid in right pleural sac. The 
systolic blood pressure, 185 mm. Hg. The urine contained a 
medium ring of albumin and a moderate number of hyaline casts; 
specific gravity, 1008. Examination of the ej^e-grounds bj^ Dr. 
J. A. Brophy revealed albuminuric retinitis and recent hemorrhages 
in both eyes. Removal of the fluid was followed by relief, but 
patient gradually became comatose, dying four days later. No 
autopsy permitted. 

I am much indebted to Dr. H. Leon Jameson for valuable aid 
in connection with the clinical records detailed above. 


CONGENITAL ATRESIA OF THE DUODENUM. 
Br Archibald L. McDonald, A.B., M.D., 

ATTE>rDING PHYSICIAN TO CHILDREN’S HOilE, DULTJTHp illNKESOTA. 


Instances of congenital atresia, or complete obstruction of 
the gastro-intestinal tract, are sufficiently infrequent to warrant 
the detailed report of individual cases Avhen confirmed by opera- 
tion or autopsy. The number of recorded cases is by no means 
large, thougib no doubt, some are not reported and many pass 
unrecognized in the absence of postmortem examination. Because 
of this assumed rarity the condition is not appreciated and the 
clinical diagnosis is not considered as probable. These malforma- 
tions are of interest; (1) as a clinical entity, difficult of recog- 
nition, and, as to prognosis, practically hopeless; (2) in its clinical 
and etiologic relationship to spasm and conditions of partial ob- 
struction of the tract; (3) the possible embryologic factors causing 
such abnormalities are of theoretic interest. 

The following case which occurred in my practice is a good 
example of a complete atresia, Muth loss of continuity of the duo- 
denum. Baby 0.; mother, aged twenty-four years, always well; 
no miscarriages; two children, aged five and three years respec- 



MCDONALD: CONGENITAL ATRESIA OF THE DUODENUM 29 

lively. Pregnancy normal; labor apparently precipitated by 
overwork about two weeks before expected date. Membranes 
ruptured, with escape of considerable fluid, at 7 A.M., December 11; 
head engaged in L. 0. I. A. by 11 A.M.; child born at 9 P.M., after 
about one hour of severe pains. Placenta and membranes normal. 
Though membranes were said to have ruptured in the morning 
and much fluid escaped during the day it was found in the second 
stage of labor that a membrane and bag of water preceded the head. 
This was ruptured, followed by a gush of amniotic fluid. Though 
not striking at the time, there was evidently an hydramnios, 
judged by the excessive amount of fluid. This is said^ to frequently 
accompany such malformations in the fetus. However, hydramnios 
is frequently observed, and its occurrence alone would hardly lead 
one to expect a gastro-intestinal abnormality. Child weighed 
six pounds eight ounces, and was apparently normal in every 
respect. 

December 12. Child had vomited in the night, had nursed well, 
and was hungry. Passed some urine, but no bowel movement; 
continued to vomit at irregular intervals during the day. 

December 13. Patient passed slightly colored meconium; 
nursed well, but continued to vomit; was restless and slept poorly; 
no urine observed. 

December 14. Baby appears emaciated and slightly jaundiced; 
abdomen distended; vomited large amounts of fluid, containing 
no bile and in no relation to feeding. Soapsuds enema brought 
away slightly colored stool. Nursing discontinued and albumin 
water substituted. 

December 15. Child still vomiting; is restless and sleeps poorly; 
no stools or urine; enema comes away clear. Stomach tube drew 
off nearly a pint of creamy fluid not bile stained. One could not 
be sure that all contents were removed, but the washings came 
away clear and the abdomen was much less distended than before. 
A diagnosis of pyloric stenosis, with probable complete obstruc- 
tion, was made, and a hopeless prognosis given. Child rested 
better for some hours, but became restless during the night and 
died at 7 a.m. 

December 16. A partial autopsy was permitted and only the 
abdominal condition will be described, since as near as could be 
determined other parts were normal. On opening the abdomen 
the distended stomach and duodenum were most prominent, but 
in normal position, as were the other viscera and omenta. The 
stomach was dilated to three times its normal size, and the duo- 
denum was much larger than the stomach. There was a definite 
constriction at the pylorus, which was, however, patent. The 
duodenum was greatlj'’ dilated, but could be traced through its 


> Little and Helmholz, Johns Hopkins Hosp. Bull., July, 1905. 
VOL. 146, no. 1. — JULY, 1913 2 





MC DONALD: CONGENITAL ATRESIA OF THE DUODENUM 


collapsed, the latter extending across the upper abdomen, with 
the cecum in about its normal' position. AppendLx long, with 
normal mesentery. Small intestine contracted and cord-like, being 
barely permeable. Its mesentery was normal, and no definite con- 
striction was found until reaching the upper end of the jejunum 
in the region of Treitz’s fossa, where it ended in a blind sac covered 
by a fold of peritoneum. Liver normal in size and position. Gall- 
bladder distended with bile. Ducts could not be traced to the 
duodenum. It is probable that no communication existed, as no 
bile was present in the vomitus or contents of the distended stomach 
or duodenum, and jaundice was present. We had then a complete 
atresia, with obliteration of a portion of the tract in the region of 
the duodenojejunal junction. 

Such malformations are not extensively discussed in text-books 
or even in the literature, except Avhen mentioned as unusual con- 
genital anomalies. There are, however, a few extensive articles 
giving descriptions of such cases and reviewing the literature, to 
which I shall refer.^ 

Defects may be found at any point in the gastro-intestinal tract, 
but are more common at the following sites and in the same order 
of frequency: (1) pylorus and duodenum; (2) rectum and anus; 
(3) ileocecal region; (4) at the attachment of Meckel’s diverti- 
culum; (5) the flexures of the large intestine. Atresia and stenosis 
of the rectum and anus really belong in a different group and will 
not be considered. Little and Helmholz were able to collect only 
27 cases of atresia of the duodenum above the papilla of Vater, 
including their own. Spriggs adds one of the duodenum, and 
reports several of the tract lower down. Clogg refers to the follow- 
ing collections of cases: Silberman, with 24 cases of atresia of the 
duodenum, and 30 of atresia, and 3 of stenosis of the jejunoileum. 
Schlegel and Braune, with 89 cases of atresia and stenosis of the 
entire tract, Cordes,^ with 48 cases of atresia and 9 of stenosis of 
the duodenum. These references are also given by Little and 
Helmholz, so it is fair to assume they include most of the cases in 
the literature. Several areas of atresia have been reported in a 
single individual. 

^ Unless the case is studied with the possibility of such a condi- 
tion in mind the diagnosis is not made until treatment is hopeless 
and most often is missed entirel 5 '^. Many such cases would be 
classed as malnutrition or spastic stenosis, unless an autopsy con- 
firmed the diagnosis of atresia. Certain symptoms and signs are 
suggestive, and if carefully studied will enable one to make a corect 
diagnosis, possibly early enough to warrant surgical intervention. 
(1) Persistent and characteristic vomiting; (2) constipation and 

= Little and Helmholz, Johns Hopkins Hosp. Bull., July, 1905; H. S. Clogg, Lancet, December 
24, 1904; N. J. Spriggs, Lancet, January S, 1910. ' 

= Archiv f. Pediatrics, 1901. 



MCDONALD: CONGENITAL ATRESIA OF THE DUODENUM 


character of the stools; (3) distention of abdomen^ visible peris- 
talsis; (4) anuria, emaciation, jaundice, and other malformations: 
(5) hydramnios in mother. Vomiting is a constant and impor- 
tant symptom, and may include amniotic fluid, and everything 
taken by the mouth. It has no necessary relation to feedings, the 
frequency and amount depending upon the size of the cavity above 
the stenosis. Bile will be present or absent as the obstruction is 
above or below the papilla of Vater. Most charaeteristic is the 
vomiting of drugs or food, given a day or so previously. A stomach 
tube should be used early in suspected cases, and will demonstrate 
the size of the viscus. Such findings are often the first indieation 
of an organic stenosis. Vomiting in the newborn is so common 
that it is often not properly appreciated, but in these cases the 
duration is short, five or ten daj'-s or less, and the progress is rapidly 
fatal, so that the symptoms should be carefully studied from the 
beginning. If the stomach is greatly dilated the abdomen will be 
prominently distended and splashing sounds may be elicited. 
There may be one or more spontaneous passages of meconium, 
or an enema may bring away some intestinal contents. In such 
cases, as with mine, one feels that the condition of the bowels is 
temporary and that the next stool will be normal. However, such 
stools rarely contain bacteria, and never, if the obstruction is com- 
plete, drugs or digested food. Bile pigments are absent if the 
obstruction is below the papilla. There may be complete obstipa- 
tion, which would indicate an obstruction loiver in the large intes- 
tine. Distention of the abdomen, with visible peristalsis, will be 
suggestive when present. 

Anuria is usually a marked symptom, due to the fact that no 
fluid is absorbed from the stomach. Emaciation is rapid and 
progressive, as the child is receiving no nourishment. Daily 
weighings will show a rapid and regular loss of weight. One might 
expect to find some form of tetany in these cases, due to the absorp- 
tion of toxins from the stomach and duodenum ; but it was not present 
in my case, neither is it mentioned in the literature. Jaundice is 
mentioned in some instances, and was marked in my ease. Other 
congenital deformities might suggest organic obstruction of the 
intestinal tract in the presence of symptoms. Hydramnios in the 
mother is said to frequently accompany, but as alreadj'’ stated is 
too common to alone suggest deformity in an otherwise normal 
child. Most of the symptoms are exaggerations of those of mal- 
nutrition, .and often do not attract great attention during the first 
day or so. The picture rapidly becomes strildng, and if one has 
followed it carefully a diagnosis of pyloric or duodenal obstruction 
should be made. 

More important and also more difficult is the differential diagnosis 
between (1) spasm of the pylorus; (2) congenital hypertrophic 
stenosis, and (3) congenital atresia, with complete obstruction. 



MCDONALD; CONGENITAL ATRESIA OF THE DUODENUM 33 

Spasm of the pylorus may be present shortly after birth, but often 
does not cause symptoms for some days, Aveeks, or even^ months. 
Usually a certain amount of nourishment passes into the intestine, 
so the emaciation is not as rapid as is the case in absolute obstruc- 
tion. The stools shoAV the presence of bacteria and digested food. 
Hypertrophic pyloric stenosis may give marked sj^mptoms during the 
first few days, but this also may be delayed for some weeks, and 
the course is not as rapidly downward. Unless the stenosis forms 
an absolute obstruction the stools will contain bacteria and digested 
foods. A palpable tumor would, of course, suggest hypertrophic 
stenosis. Vomiting is a marked symptom in both the above condi- 
tions, but emaciation and malnutrition are slower in their develop- 
ment. In a case of congenital atresia, or complete obstruction, 
the symptoms must be more marked and rapidly progressiAm than 
in those of relative stenosis from spasm or hypertrophy. 

The prognosis is bad in all cases of CAmn relative obstruction 
in the ncAA^born because of the diflSculty of nourishing the child, 
and is practically hopeless in case of complete congenital atresia. 
Hypertrophic pyloric stenosis is Avell recognized and discussed in 
the literature. There are several reports of successful surgical 
treatment of these cases and a fcAv instances of medical treatment, 
though in the latter group the diagnosis must remain in doubt. 
In the complete obstruction or atresia the condition is absolutely 
hopeless unless the continuity of the intestinal tract can be re- 
established by surgical procedure. So far as I can find in the 
literature no such successful operation has been reported, though 
many have been attempted. There are sCA’^eral factors AA'^hich are 
unfavorable to a successful outcome. The diagnosis is rarely 
made before the child is emaciated and in poor condition to undergo 
operation; the intestine in the ncAvborn is normally small, render- 
ing an anastomosis difficult at best; the portion of intestine beloAV 
a congenital stenosis or atresia has been empty and collapsed for 
months, and perhaps has ncA'^er been patent. Other obstructions 
may be present lower in the tract. In my case the distal portion 
Avas almost a solid tube, with only a small lumen. NeAmrtheless 
in vicAv of the absolutely hopeless prognosis if let alone, operatiAm 
treatrnent AAmuld be indicated as early as the diagnosis of complete 
obstruction is made. It is to be hoped that early diagnosis and 
improAmd operative technique may saAm a baby otherAvise doomed 
to starvation. The practically fatal prognosis should be explained 
to the parents before a surgeon is asked to take the responsibility 
of operation. Little time should be spent in searching for the 
obstruction, as the condition of the tract above and beloAV aauII be 
sufficient to indicate the sight. Gastro-enterostomy is the opera- 
tion of^ choice. If the obstruction is much loAA^er an enterostomy 
may give temporary relief, and the infant brought into better 
condition to undergo a final operation. 



34 IMC DONALD; CONGENITAL ATRESIA OF THE DDODEETBI 

It is stated that most congenital atresias develop before the 
foDrth month of intra-uterine life, since bile is not found in the 
distal portion of the intestine. This would fix the time of develop- 
ment before certain important embryologic changes have taken 
place and to some extent would limit the possible causal factors. 
Might it not be possible, however, for a certain amount of bile 
to be absorbed from the fetal intestine into the portal circulation, 
leaving little trace of its presence. Some of these obstructions 
might therefore be supposed to occur at a later period. The theories 
advanced to explain these anomalies are numerous and interesting. 
The inflammatory theory explains them as being due to adhesions 
following fetal peritonitis. Ascites has been described in some 
cases of congenital obstruction, but extensive adhesions are rarely 
found. Fetal peritonitis, especially in the early months, is not a 
common finding, and must be limited to the tuberculous or syphilitic 
forms. It is improbable that a fetus affected with syphilitic peri- 
tonitis of sufficient intensity to cause atresia of the intestinal tract 
would go on to full term, much less develop as an otherwise healthy 
child. Few if any of these cases have shown signs of congenital 
sj'philis in life or at autopsy. Fetal tuberculous peritonitis is rarely 
found, and it is hard to believe that only a part of’the tract could 
be involved, leaving no other evidence of the disease. Fetal inflam- 
mation may explain isolated cases, but will not cover the majority 
of them, Pearce-Gould, in 1882, described a case in which the cecum 
and ascending colon were filled with a plug of cheesy mucus adherent 
to the intestinal wall. This instance could be explained on the 
intussusception theory, as advanced by Chiairi, who found an 
atresia 15 cm. above the cecum, with a cylindrical intussusception 
in the distal portion of the colon. This might explain cases of 
atresia of the lower bowel more often than is evident at first thought 
as the necrotic bowel may be disintegrated or absorbed, leaving 
little proof of the original condition. However, it can hardly explain 
such anomalies of the pylorus or duodenum. Fetal volvulus, adhe- 
sions of Meckel’s diverticulum, and an inclusion of a part of the 
intestine in the closing umbilical ring may cause kinking, occlusion, 
or atresia of the small or large intestine, but probably do not affect 
the duodenum. Bland Sutton, in 1889, advanced the idea that 
most of these malformations were due to errors in development, 
the most frequent locations of Avhich correspond with the sites of 
important embryologic events. For example, the most frequent 
locations of atresia are: (1) pylorus and duodenum, the site of a 
complicated rotation as well as the outgrowth for the liver and 
pancreas; (2) the ileum, especially at the attachment of Meckel’s 
diverticulum; (3) ileocecal region, where there occurs a rotation 
and what is essentially an outgrowth of the saeculated cecum and 
appendix; (4) the region of the flexures is a less frequent site of 
malformation and of less importance embryologically. The most 



MC DONALD : CONGENITAL ATRESLI OF THE DUODENUM 35 

important embryologic changes in the intestinal tract occur in 
the region of the pylorus and duodenum, hut normally result in a 
patent continuous tube. The duodenum is relatively fixed at the 
pylorus and at its junction with the jejunum, and the tract under- 
goes a double rotation about these points. ^ The outgrowths for 
the liver and pancreas make in all a complicated^ picture, which, 
however, normally results in a patent continuous intestinal canal. 



Eig. 3. — Arteries of alimentary tract in human embryo at six weeks: 1, gastric artery; 
2, pyloric artery; 3. superior pancreaticoduodenal branch of hepatic; 4, superior pancreatico- 
duodenal branch of superior mesenteric. I, anastomosis between gastric and pyloric branches 
of licpatic; II, anastomosis between pyloric and superior pancreaticoduodenals; III, anas- 
tomosis between superior pancreaticoduodenal brancli of hepatic and inferior pancreatico- 
duodenal branch of superior mesenteric. (Modified from Kollmanns.) 


Likewise at the other sites mentioned the development offers oppor- 
tunity for deviation from normal and possible occlusion of the 
canal. However, obstruction does occur at regions where no very 
complicated event takes place, and must be explained on other 
grounds. Also some additional factor is required to explain the 
deviations from normal in the above-mentioned sites. This has 
been suggested by Joubalay in the idea of congenital vascular 
anomalies. Little and Helmholz quote a case of atresia of the 



3G MCDONALD: CONGENITAL ATRESIA OP THE DUODENUM 

duodenum above the papilla in which there was an absence of tlic 
superior pancreaticoduodenal artery, and in their own the superior 
pancreaticoduodenal, pyloric, and left gastroepiploic arteries were 
wanting. The blood supply of the fetal gastrointestinal tract below 
the diaphragm is from three main aortic branches which anastomose 
freely. (See Fig. 3.) 

That of the pylorus and duodenum is from three sources whose 
branches anastomose freely: (1) a branch from the gastric, which 
anastomoses with a branch from (2) the hepatic, the pyloric. The 
hepatic also gives off the gastroduodenal, which divides into the 
right gastroepiploic and superior pancreaticoduodenal. This latter 
anastomoses freely with the inferior pancreaticoduodenal from the 
(3) superior mesenteric. We have then a blood supply from three 
sources which anastomose freely, and should normally secure 
efficient nutrition to all parts. Vascular anomalies are not infre- 
quent, and we hax^e here several places where an occlusion or 
absence of a normal branch might interfere seriously with develop- 
ment of the part, thus leading to partial or complete atrophy. This 
would be marked by kinking, stenosis, or obliteration of a part, 
with complete atresia. This is most likely to occur at the pylorus, 
where branches of the gastric and hepatic anastomose, and at the 
lower portion of the duodenum supplied by branches of the superior 
and inferior pancreaticoduodenal. Such vascular anomalies are 
perhaps most frequent in the duodenal region, but the same possi- 
bility exists at manj^ points in the tract. The branches of the vasa 
intestina tenuis of the superior mesenteric are essentially terminal, 
and there is little anastomosis between them. Occlusion of one 
or more of these offers an explanation of atrophy of the small 
intestine. Whether the fusion of the fetal “intestinal segments” 
as described by Mall present sites of possible stenosis or occlusion 
is also an interesting question. A study of the vascular supply 
to the ileocecal region and its development offer several points 
where the chain may be broken and an area left without sufficient 
blood supply. 

Such factors then as inflammatory^ adhesions, volvulus, occlu- 
sion by intestinal contents, may explain an isolated case, and this 
has been apparently demonstrated by careful autopsy dissection. 
However, there remains a large number not satisfactorily explained 
by any of these causes. The fact that the majority of these mal- 
formations occur at regions where important embryologic events 
take place renders their explanation as due to developmental error 
plausible. Together with this we must consider the relation of 
vascular anomalies as exceedingly important. In fact, I believe 
these two factors are interdependent, and will explain most of the 
cases under discussion. 



pitpield: kecovery from tubercular meningitis 


RECOVERY FROM TUBERCULAR MENINGITIS, WITH 
REPORT OF CASES. 

By Robert L. Pitfield, M.D., 

PHYSICIAN TO ST. TIMOTHY’s AND GERMANTOWN HOSPITALS, PHILADELPHIA, 

McCarthy in the Phijjps histihite Reports for 1908 remarks 
“'that evidences of recovery in tuberculosis of the nervous system 
is as rare as it is common in the lungs.” That there is a retrograde 
process in tuberculosis of the glands, bones, peritoneum, and lungs 
is, of course, a trite observation. 

In the nervous system occasionally tuberculous processes calcify, 
and meningeal infections become fibrous, quiescent, and finally 
heal. That such is the case in meningitis of tubercular origin has 
been a matter of comment by quite a number of writers, notably 
by Martin, in Brain for 1908, who has collected a series of cases 
in which recovery took place. In all text-books the prognosis is 
put down as grave or always grave. Dieulafoy mentions but 
one case that recovered, but he evidently had not scanned the 
literature thoroughly, because in his own country at the time at 
which his book was written there were records of at least six or 
seven cases of undoubted tubercular meningitis followed by recov- 
ery. But even the most optimistic must agree that it is always best 
to tell the family of one stricken mth this disease that the outlook 
is practically hopeless; nevertheless, one must do so guardedly, 
and follow out certain lines of rational treatment, to be detailed 
later, in the hope that the lesions may be limited to the cortical 
membranes of the brain, without exudation of fibrin or purulent 
matter, and may not extend into the ventricles. 

There are, of course, several meningeal diseases closely simulating 
tuberculosis, and these must be considered in several ways. These 
are, notably: (1) Quincke’s disease, in which there is simply an 
excess of eerebrospinal fluid, chiefly in the ventricles, not produced by 
microorganisms and not infectious; (2) influenzal meningitis, simu- 
lating it closely, (3) and the meningismus of t 3 ^phoid. Hereditarj^ 
syphilis in the young, too, may resemble meningitis of tubercular 
origin. From the faet that Quincke’s disease, which is not of para- 
sitic origin, and therefore probably not toxic in the character of 
the serous exudate, ean simulate true meningitis, it is evident that 
simple pressure within the ventricles and hence to the skull may 
cause ner^mus sj^mptoms, chiefly cephalalgia in both disorders. 
In meningitis the added poisons and the multiple tubercles massed 
in nerve trunks and fibrous purulent exudate add much to the 
pathologj'' and to the gravity of the prognosis. 

A typical case of influenzal meningitis is the following; A jmung 
grocer, aged twenty-seven years, married, father of one healthy 



38 pitpield: eecovery from tubercular meningitis 

child, was one evening suddenly seized with a violent headache. 
This did not yield to any of the ordinary headache remedies, 
so that by morning morphine was required. Then it was seen 
from the retraction of the neck, intense pain, retracted belly, tache 
cerebrale and Kernig’s sign, fever, photophobia, and delirium, that 
meningitis was present. Accordingly, a lumbar puncture was 
done and 70 c.c. of clear liquid were drained off. This contained 
a fibrin clot, lymphatic cells exclusively, and no organisms. The 
headache immediately disappeared, Kernig’s sign and rigidity of 
neck did so after ten days. He gained weight and resumed business. 
Two months afterward a second attack necessitated another punc- 
ture. He then had double vision on looking down and marked 
abduction of the eyes; jerking of the eyeball was demonstrable. 
Thotophobia, increased knee-jerks, plantar flexion of the toes, tache 
cerebrale, rigidity of the neck on the right side appeared. At this 
time headache did not seem so intense, and there was not so much 
fever. In removing 35 c.c. of fluid the double vision and fulness 
of the head disappeared during the operation, and the patient 
became markedly better. The fluid was limpid, clear, but contained 
some minute bacilli, probably influenzal. A guinea-pig injected 
with the fluid recovered. In twenty days all symptoms of any 
disorder promptly disappeared, save some stiffness of the neck. 
This was probably a case of influenzal meningitis, with lymphocy- 
tosis, cured by lumbar puncture and urotropin, which was freely 
given. There was no history of syphilis in the case, and the 
Wassermann test was negative. 

The following is the history of a case of tubercular meningitis 
with recovery; 

J. S., aged fifty years, linen draper, was admitted to St. Timothy’s 
Hospital \vith every symptom of meningitis, from which he had 
.suffered for four or five days. He had had such an intense headache 
that be begged to be shot, and indeed a revolver in his room had to 
be removed for fear that he would do so. When admitted he was 
delirious and had a retracted neck, scaphoid belly, and tache cere- 
brale. A lumbar puncture was done under chloroform and 80 c.c. 
of fluid were vnthdrawn. He was a very tall man, measuring over six 
feet four inches, but was far from robust. In each apex there was 
evidence of tuberculosis, which from his history had existed for some 
time; in every way his history was that of one who had a low-grade 
phthisis for ten years. The present attack came on with violent 
vomiting and unendurable headache, also pains in his arms and 
legs. Kernig’s, Oppenheim, and Babinski’s signs were all present 
markedly. Pupils were contracted and rigid. On attempting to 
flex his neck after the lumbar puncture all the major joints flexed, 
and he groaned. 

The lumbar puncture was easily performed, the fluid spurted out, 
and was quite bloody, due to the puncture of a small vein. This 
fluid contained three acid-fast bacilli, which in view of the presence 



pitfield: recovery from tubercular meningitis 39 

of tuberculosis of the lungs were assumed to be tubercle bacilli. No 
animal injections were made. A cytodiagnosis was not attempted 
because of the admixture of blood. His pulse was 70; respiration, 
26 and jerky; temperature, 99°. His leukocytes numbered 6200; 
red cells numbered 4,200,000; hemoglobin, 75 per cent. His urine 
was bloody, and contained albumin and casts. Blood pressure: 128. 
systolic; 88 diastolic. Marked improvement followed the with- 
drawal of the fluid. His spastic symptoms slowly receded. His mind 
became clear in a few days and his headache disappeared. He was 
given forced diet and urotropin, 30 grains a day. After three weeks’ 
stay in the hospital, to the amazement of all, he suddenly got up, 
asked for his clothes, and went home. He then had some rigidity 
of his neck and some evidences of Ivernig’s phenomenon. After 
two years he is able to conduct his business and has no evidences 
whatsoever of any meningitis. In this instance the fact that 
the patient was an adult and long infected with a low-grade 
tuberculosis no doubt contributed much to his recovery. 

Perhaps the most interesting case of reeovery after tubercular 
meningitis is that reported by Rumple (quoted by Martin), who 
exhibited at the Aerztlichen Verein, Hamburg, the brain of a boy 
who died of phthisis. At the age of nine the boy had an acute 
attack of meningitis, in which there was retraction of the neck and 
hyperesthesia, absence of knee-jerks, bilateral optic neuritis, ptosis, 
and palsy of the external recti. Lumbar puncture gave a fluid in 
which tubercle bacilli were found. The boy, who was treated with 
repeated lumbar punctures, recovered, and though for some months 
was dull and stupid, he eventually retained his normal mental 
condition and was able to keep pace nnth other children of his 
age at school, while all physical signs had disappeared. Four years 
his health continued good, he then developed a tubercular abscess 
in the axilla, followed by phthisis; death took place eight years after 
the onset of the meningitis. At autopsy it was found that the 
membranes over the fissure of Sylvius on either side of the brain 
were thickened and glued together, but miliary tubercles were no 
longer visible. Not only was there a confirmation during life of 
the presence of tubercular meningitis, by the finding of tubercle 
bacilli, but also post mortem, at which the site of the old infection 
was discovered and definitely identified. Martin sums up the fol- 
lowing requirements to be met in making a diagnosis of tubercular 
meningitis followed by recovery : 

1. Clinical evidence of tuberculosis elsewhere in the body and 
history of exposure. 

2. Differential count of cells in the spinal fluid (meaning an excess 
of lymphocytes). 

3. Presence of tubercles in the choroid. 

4. Tuberculin reaction. 

5. Demonstration of bacilli in the fluid by staining, inoculation, 
and culture. 



40 pitfield: recovery from tubercular meningitis 

6. Postmortem examination after recovery or long remission and 
death by some other agency. 

If tuberculosis of the meninges be but a local manifestation of 
a generalized infection (miliary tuberculosis) then the likelihood of 
recovery is of course minimized. That it is likely under such cir- 
cumstances, is evidenced by cases reported by Lunn, (1) Dujardin- 
Beaumetz (2), Thornalas (1), and Brooks (2), in all of these tubercles 
veie seen in the choroid, indicating a generalized infection. Tuber- 
culin reaction, of course, confirmed the diagnosis, but it does not of 
necessity prove that there may not be some other remote latent 
infection which is the cause of the reaction. Postmortem examina- 
tion and clinical diagnosis of tuberculosis elsewhere are, of course, 
convincing confirmation that the disease is tuberculosis. 

In the case of a young woman, recently under the care of the 
writer, who had severe retractions of the neck, with pain, photopho- 
bia, increased knee-jerks, tache cerebrale, tuberculous apex, bilateral 
pleurisy, high fever, and definite history of exposure to tuberculosis 
in her home, lumbar puncture revealed nothing and did not alleviate 
symptoms a particle. A later development of iritis and arthritis 
of the elbow compelled a revision of diagnosis to rheumatism of 
the spine, pleura, joints, and eye, showing that mere dependence 
upon the previous existence of a latent tuberculous lesion for 
confirmation was misleading and not dependable. Cytocliagnosis 
is also misleading. Porat reports cases shoving that it may be value- 
less. Forbes, who examined SO cases, 70 being verified by autopsy 
or by finding tubercle bacilli, found 51 had an excess of lymphocytes, 
5 had an excess of polymorphonuclears; in 4 the proportion was 
equal. In tuberculosis of the brain not communicating with the 
meninges the fluid was normal. Goggia found an excess of lympho- 
cytes in a meningococcus infection. Mutzner concludes, from a 
study of a series of cases with postmortems, that a lymphocytosis 
is not by any means diagnosed, and reports cases with an excess of 
the many nuclear forms of leukocytes. 

In 797 cases collected by Martin for the London Hospital of 
unconfirmed tubercular meningitis, 16 (or 2 per cent.) recovered. 
In Vienna 1369 cases were reported in which recovery took place 
in 6 (or 4.4 per cent.). Thus in a total of 2166 cases, 22 (or about 
1 per cent.) recovered. These, of course, were diagnosticated from 
mere clinical symptoms. Barlow, also quoted by JMartin, states that 
if the tuberculous process be limited to a part of the surface of the 
brain there is a possibility of recovery, but if the disease, becomes 
generalized so that besides the invasion of the pia mater there is an 
extensive meningo-encephalitis, with or without hydrocephalus, the 
chances of recovery are practically nil. 

^McCarthy in several Phipps IvMitutc Reports found frequent 
eHdences of healed tuberculosis of the nervous system iii^subjects 
that had finally died of phthisis. 



PITFIELD RECOVERY FROM TUBERCULAR MENINGITIS 


41 


True Cases. 


Case. 

Autopsy. 

Bacilli 

1 found. 

1 Tuberculosis 
elsewhere in 

1 body. 

Cytodiag- 

nosis. 

Tubercles in 
choroid. 

] Clinical 

1 diagnosis. 

Tuberculin. 

Tuberculous 

history. 

Treyhan. 

Henkel, 17 yrs. 

None, 

recovered 

1 None, 

1 Yes 

1 Yes 


1 

1 

1 

f . . 

1 

s 

o 

2: 

’Yes' 

lYes 

i 

I None 

i .. ; 


Gross, 20 yrs. 

Stark, 44 yrs. 
Barth, 3 yrs. 

Stiles. 

Stiles. 

Alanzino. 


recovereu i 

None, ' Yea 
recovered 
None 
None 


None 

None 

None 


Tedeschi, 14 j’rs. 
Jemma, 31 yrs. 

None 

None 

Gareiso, 8 yrs. j 

None 

Glaisso, SOyrs. i 
Abramo. / 

Dufour. 

Dufour. 1 

Vaquez- 

Digne. 

Rossini. 

None 

Yes 

Y'es 

Janssen, 19 yrs. 

Yes 

Politzer. 

Yes 

1 

Schwalbe. 

j Y'es 

Schwalbe. 

1 Yes 

Carrington. 

Yes 

Leube, 24 yrs. 

j Y'es 


Yes 'E.\cess 
I polys. 

Ygs 

Yes ;None , None 

1 

Yes jNone j 

Yes iNone 

Yes ;None ' Yes 
G.P. 

Yes None 
Yes None 

Yes |None 

Yes None 


. I Yes' 
1 

None I Yes 
None i . . 

None Yes 

None Sycs 

. . Yes 


Yes . 
Yes i 


Yes 

Yes 


Yes 'None !Yes 


Yes 


I Yes 
G. P. 
Yes 
G.P. 


Yes ■ Yes 

1 


I Yes 
Yes 
|Yes 

Yes 

Y'es, 


I 


Yes 

Yes 

Yes 

Yes 

Yes 


I 


Riebold, 6 yrs. j 

None 1 

G.P. ' 

I 

.. Yes .. j 

i 

Rumpel, 17 yrs. 1 

1 les 

Yes ,G.P. 1 

Yes 1 

.. 1 .. Yes .. ! 

i 

1 

Lunn. 

1 

1 

None 

Yes. 

1 

t 

1 

, 1 

. , 1 Yes : 

Yes . . 

Dujardin- 

! None ' 

None 

None 

. . ' Yes Yes 

Beaumetz. 

Thornallas. 

! None 

1 

None 

1 

1 

Yes ; 

' i 

None • Yes 

1 1 

Y'es 

1 

W. T. B rooks , 4 y rs . 

1 

' Yes 

Yes : 

1 1 

Yes 

1 1 
Yes 1 Yes 1 

Yes| Yes 

Pitfield, 55 j-rs. 

None 

Yes j 

Yes 

i ■ 

i i 

Yes ,None 

t 1 

1 
i 

i 

YeS| None 

1 

t 


Choked disk. 


I Developed ijlitliisis 
8 months after. 

I Optic neuritis. 

Recovered in 0 
months. 

Recovered after de- 
compression. 

Recovered after de- 
compression. 

Recovered in good 
health, 6 months. 

After 3 j'ears, good 
health. 

Well 12 months 
after. 

I Satisfactory recov- 

I ery. 

j Old tubercles found. 

Old tubercles found. 


Complete recovery. 

Meningitis 3 years 
before death from 
phthisis. 

Old lesions and new 
lesions, 3-year in- 
terval between at- 
tacks. 

Both died of diph- 
theria. 

Evidence of old tu- 
bercles found at 
autopsy. 

Died of psoas ab- 
scess. 

Died of phthisis and 
recurrent meningi- 
tis. Old tubercular 
lesion of brain 
found from pre- 
vious attack. 

574 c.c. drawn in 
punctures. 

Died of phthisis 4 
years after recov- 
ery from menin- 
gitis. 

Meningitis followed 
by recovery. 
Recovery: diagnosis 
based on choroid 
tubercle. 

Tubercles seen in 
choroid : disap- 

peared on recov’y. 
Autopsy showed old 
healed meningitis: 
subsequently died 
after a long period . 
Yes 1 Recovery, 3 weeks: 
old tuberculous 
lesion of the lungs. 


I am able to append 29 cSses of undoubted tuberculosis, mostly 
collected by Martin, in which recovery followed and 8 others more 
doubtful. In 10 autopsy confirmed the early diagnosis. In 18 



42 


SILER, garrison; the epidemiology of pellagra 


tubercle bacilli were detected and in 5 of these guinea-pig inocula- 
tion confirmed the diagnosis. In 4 cases, tubercles of the choroid 
were seen. In 7 demonstrable tuberculosis elsewhere was noted. 

In ^dew of the fact that recovery can take place in perhaps 1 in 
200 cases, steps should be undertaken actively to facilitate such 
a possibility. The patient should be put in a quiet, airy, dark 
place and kept as free from annoyance as possible. Lumbar punc- 
ture should be performed at once. The writer had a case, a boy, 
aged five years, from whose spine 40 c.c. of fluid were removed 
every other day for two weeks, with marked amelioration in the 
symptoms. Forced feeding through nasal tube, with milk and eggs, 
should be done. Morphine administered for pain and as a sedative, 
if respiration is not embarrassed thereby, and because free formal- 
dehyde is found in the spinal fluid after the ingestion of urotropin 
the latter drug should be given freely. I have found, after giving 
it for one day, that formaldehyde can be detected in the fluid with 
iron and sulphuric acid; and because Raw has reported recovery 
in two cases in wliich tuberculin was used, I would advocate one 
or two injections of this remedy. 

One case was most skilfully operated on by Dr. George Muller, 
who decompressed and punctured the left lateral ventricle, with- 
drawing about four times the normal amount of fluid, the child 
ultimately dying of respiratory palsy, having lived for three weeks 
after the diagnosis had been made and gaining five pounds by 
forced feeding. Why decompression is not fraught with better , 
results in this disease is probably due to the involvement of the 
ventricles. The unrelieved distention is due to the choking of the 
canal leading from the third to the fourth ventricle. 


AN INTENSIVE STUDY OF THE EPIDEMIOLOGY OF 
PELLAGRA. REPORT OF PROGRESS.^ 

By Joseph F. Siler, B.S., J\I.D., 

CAPTAI.V, MEDICAL CORPS, UNITED STATES ARMY, 

AND . 

Philip E. Garrison, A.B., M.D., 

PASSED ASSIST.\NT SURGEON, UNITED STATES NAVY. 


(From the Laboratorj’^ of Tropical Medicine, New York Post-Graduate Medical School.) 


Part I. 

I. General Plan of the Work. Although the Thompson- 
McFadden Pellagra Commission will continue its work in the field 

I From the Thompson-McFadden Pellagra Commission, New York Post-Graduate lUedical 
School and Hospital. 



SILER, garrison: the epidemiology of pellagra 4:6 

during 1913, it is considered advisable and warranted to set forth 
at this time in a brief preliminary report certain results of the 
epidemiological study made in 1912, 

It was decided that an intensive study of the disease as it 
occurred among the population of a limited area would yield more 
valuable epidemiological information than a more superficial inves- 
tigation over an extended area, conducted by correspondence and 
by brief studies in a number of different localities. No such inten- 
sive epidemiological study within a small area seems to have been 
previously undertaken in pellagra, while much data gathered by 
the more general methods are already available in the literature. 

For the collection of data a blanlc booklet was prepared, covering 
points considered of possible significance regarding the patients 
themselves, their families, their residences, and the neighborhood 
in which they lived. In order to secure these data, each patient 
was visited one or more times in his or her own home. 

In this preliminary report only summarized data will be included. 
The detailed epidemiological data for each case, and certain more 
intensive studies made in selected localities within the county, 
will appear in the report to be issued on completion of the inves- 
tigation. 

The problem immediately before the commission in all its work 
was the etiology of pellagra and not its symptomatology or thera- 
peutics, except as these subjects might throw light upon the 
essential nature of the disease. In view of the essential importance 
of diagnosis in our work, the conservative position was taken that 
a positive diagnosis would be made only when the characteristic 
skin lesion was evident or its earlier presence could be . definitely 
ascertained by the testimony of patient and physician, though this 
requirement might, and ultimately did, exclude from our records 
cases which in all probability were suffering from pellagra without 
showing evidences of its cutaneous manifestation. 

II. Acknowledgments. It is not practicable to make personal 
acknowledgment in each case to the many physicians to whom 
we are under great obligations for their interest and coopera- 
tion. The Spartanburg County Medical Society supported us in 
all our work, and we wish to express our high appreciation of its 
active part in furthering the investigation. Our only way of 
approaching patients was through their local physicians, and in 
no case did we find anything but the most ready cooperation on 
the part of the physicians, while many actively associated them- 
selves in the work at a considerable expenditure of time and effort. 
In the more intensive studies in selected localities, which will 
appear in a future report, opportunity will be given us to make 
acknowledgment of these special services. 

We are indebted to Dr. J.'W. Babcock for the privilege of con- 
sulting with him from time to time during the work, and for many 
special services, especially for data concerning pellagrins admitted 



' 44 SILER, garrison: the epidemiology of pellagra 

to the State Hospital for the Insane from Spartanburg County and 
for pathologic material collected at autopsies in that institution. 

To Dr. J. A. Hayne, secretary and health officer of the South 
Carolina State Board of Health, we are under obligations for his 
interest and cooperation in our investigations, and particularly for 
furnishing from his office vital statistics concerning pellagra. 

HI. The Territory Selected. Spartanburg County is situ- 
ated in the northern or Piedmont section of South Carolina. It 
is forty miles long in a north-south direction, thirty miles from east 
to west, and contains 762 square miles. Its surface is hilly and 
broken by a network of small streams and by four small rivers 
which, with their tributaries, flow across the county in a south- 
easterly direction, one of these rivers forming the county line on 
the south. The elevation above sea level at Spartanburg, the county 
seat, is 875 feet. To the nortlnvest the slope is upward, the north- 
west corner of the county being situated at the foot of the Blue 
Ridge Mountain range, while to the south and east the elevation 
becomes somewhat lower than at Spartanburg, but with no preci- 
pitate fall, the whole county thus resting upon a plateau about 
700 feet above sea level. 


Table I. — Population Spartanburg County Census 1910. 




Total. 

One year. 

One to four years. 

Five years. 

Six to nine years. 

Ten to fourteen years. 

Fifteen to seventeen years. 

Eighteen to nineteen years. 

Twenty years. 

Twenty-one to forty-four 
years. 

Forty-five years and over. 

Unknown. 

Total population 


S3, 405 

2,733 

10,091 

1 

2,370 

8,852 

1 

10,402 5,710 

3,87.8 

1,870 

20,2391 

11,101 

159 


M. 

41,719 

1,425 

5,107 

1,171 

4,490 

5,270 

2,840 

1,903 

893 

12,822 

5,652 

so 


P. 

41,740 

1,308 

4,924 

1,199 

4,302 

5,132 2,870 

1,975 

977 

13,4171 

5,509 

73 

Native vhitc — ‘ 


50,530 

1,918 

0,842 

1,587 

5,834 

0,742 3,874 

2,570 

1,254 

17,677 

8,149 

83 

native parents 















M. 

28,472 

991 

3,526 

793 

2,909 

3,404 1,907 

1,280 


8,820 

4,003 

47 


P. 

28,004 

927 

3,310 

794 

2,805 

3,278 1.907 

jl.296 


8,857 

4,086 

30 

Native white — 


309 

5 

28 

s 

29 

31 

27 

8 

0 

111 

54 

2 

foreign parents 















M. 

150 

2 

15 

0 

11 

12 

14 

3 

2 

55 

30 



P. 

159 

3 

13 

2 

18 

19 

13 

5 

4 

50 

24 

' 2 

Foreign-born 














rvhitc 


203 


1 


1 

4 

C 

7 

5 

98 

80 

1 


M. 

130 





3 

5 

0 

5 

64 

53 



P. 

67 


1 


1 

n 

1 

1 


34 

27 

1 

Black 


21,944 

037 

2,075 

035 

2,445 

3,018 1.480 

1,098 

500 

0,910 

2,467 

07 


M. 

10,893 

335 

1,338 

299 

1,244 

1,489 

702 

530 

230 

3,289 

1,335 

30 


P. 

11,051 

302 

1,337 

330 

1,201 

1,529 

724 

508 

270 

3,021 

1,132 

31 

Mulatto 


4,400 

172 

544 

140 

543 

007| 

310 

189 

99 

1,441 

409 

6 


M. 

2,005 

97 

288 

73 

200 

302 

152 

84 

38 

593 

109 

3 


P. 

2,401 

75 

250 

07 

277 

305 

104 

105 

61 

848 

240 

3 

Indian 


4 

1 

1 







1 

1 



ivi. 

1 



. . 







1 



F. 

3 

1 

1 







1 



Chinese 


2 



. , 

. , 





1 

1 



M. 

2 



, , 


. . . 




1 

1 



P. 













Japanese 


1 






1 







P. 

1 





t 

1 








SILER, garrison; the epidemiology of pellagra 45 

The annual mean temperature, as recorded at Spartanburg, is 
60° F. While the winters are mild, killing frosts are apt to occur 
from November to March inclusive, and the normal mean tem- 
perature for the months of December, January, and February is 
about 42° F. 

The total population of the county is 83,465. Spartanburg, with 
a population of 17,517, is the only city in the county, the remaining 
population (65,948) being distributed upon farms, in cotton-mill 
villages, and among eleven small towns, only two of which have 
over 1000 inhabitants. The density of population, as a whole, is 
109 per square mile; for the rural population (that is, outside of 
Spartanburg City) it is 86.5. While in South Carolina, as a whole, 
the negroes form 55 per cent, of the total population, in Spartanburg 
County the whites predominate numerically in the proportion of 
somewhat over two whites to one negro — ^there being a white popu- 
lation of 57,055, and 26,410 negroes — ^the percentage being 68.4 
per cent, whites and 31.6 per cent, negroes. The distribution of the 
population of the county by race, nativity, age, and sex, according 
to the United States Census of 1910, is set forth in greater detail 
in Table I. 

The chief industry, and almost the only industry conducted 
upon a large scale, is that connected with the cotton mills. There 
are about twenty-eight cotton mills in the county, each mill sup- 
porting its mill-village. These mills give employment to approxi- 
mately 10,000 operatives, representing about 4000 families, and a 
total mill-village population of about 20,000. As the mill oper- 
atives are whites exclusively, it follows that something over 35 
per cent, of the white population of the countj" is found in the mill- 
villages and is supported by the cotton-mill industry. The mill- 
village population contains no foreign element, but is drawn 
altogether from the general native-born population of South Caro- 
lina, North Carolina, Tennessee, Kentucky, Georgia, and other 
nearby States. An effort is made by the mill operators to secure 
families with the maximum number of individuals capable of em- 
ployment as operatives. The income of the mill workers ranges 
from about 75 cents per -day to %2 or even more, averaging about 
$1.25 per day. 

The chief agricultural pursuit throughout the county is cotton 
culture, though in recent years more and more land has been turned 
over to corn and other grain crops. The average value of farm 
lands, $36,042 per acre, is considerably above that found in many 
sections of the Soutk'fn States. 

IV. Prevalence of Pellagra in the County. Altogether, 
282 cases of pellagra were studied in detail during the period the 
commission was working in the county, that is, from June 1 to 


- United States Census Bureau. 



46 SILER, garrison; the’ epidemiology of pellagra 

October 15, 1912, and these 282 cases are the basis for the greater 
part of our study. For the purposes of certain special lines of 
inquiry, such as the history of pellagra in the county, the geo- 
graphic distribution of the disease at different periods, the sequence 
of cases in different local areas, and the possible increase or sub- 
sidence of the malady with regard to both frequency and virulence, 
records were secured of cases known to the physicians of the county, 
but which had died or moved beyond the county limits. It should 
be said also that the 282 cases on our list as present in the county 
in 1912 represent the minimum figures for the county in this period. 

Accepting 282 as the minimum number of cases, we have in 
Spartanburg County, in 1912, a minimum morbidity rate for the 
population, as a whole, of 0.35 per cent, or 35 cases of pellagra 
for each 10,000 of the population. 

Including 94 additional cases of which we secured definite know- 
ledge in the county in 1912, but were not able to visit, usually be- 
cause of their early death or their commitment to the State Hospital, 
the total number of cases in the county becomes 376, or 44.9 per 
10,000 of population. We believe this rate represents very nearly 
the actual prevalence of pellagra in 1912 in the territory studied. 

In view of the fact that this rate is considerably higher than has 
previously been reported in any single territory of like area, it 
should be distinctly understood that in no other territory in the 
United States has so intensive a study been made and pellagrins 
so thoroughly sought out. Abundant evidence was gathered that 
the disease is at least equally prevalent in adjoining counties of 
South Carolina and in certain parts of adjoining States. Further- 
more, in Lavinder’s extensive compilations of statistics of pellagra 
in 9 Southern States, 4 States show a greater number of cases 
than does South Carolina, and 2 States a higher rate per 10,000 
of population. Referring to Spartanburg County, Lavinder justly 
recognizes the exceptional interest displayed by the physicians 
of the county in the disease, and considers his reports from this 
county to be exceptionally complete. He was able to get reports 
of 226 cases up to the beginning of 1912. Our more intensive 
search, confined to the one county, discovered a total of 398 cases 
prior to 1912. The difference of 172 cases might be considered 
surprisingly small were it not for the unquestionable fact that the 
reports obtained by Lavinder from Spartanburg County were excep- 
tionally complete. There can be no question that the excessive 
number of cases for Spartanburg County, which appears in both 
Lavinder’s figures and ours, represents more complete returns, 
and not a greater prevalence of pellagra than is present in other 
localities from which reports are less satisfactory. 

V. Geographical Distribution op Pellagra Within the 
County. In order first to investigate the possibility of ^ any 
geographical inequality in the distribution of the disease within 





3EMI0L0GY OF 

e have • conside 
;ownships sepa: 


mMim 


Map 1.— Geographical distribution of cases in county and city of Spartanburg in 1912. 

By referring to Map 2 it is seen that the township rate per 
10,000 of population ranges from no cases in township H to 71 
cases per 10,000 of population in township D. It is noteworthy, 
further, that the three townships C, D, and E, stretching across 






48 SILER, garrison: the epidemiology of pellagra 


the middle of the county, give rates of 43, 71, and 58 cases respec- 
tively, or a combined average of 55 per 10,000; while townships 







--2&^;io,ooa 




Popi 12073 
, ® e s « 

.,:S¥S.|!l 0 r 600 


Pop.5256 
' Sealses - ' 
15 >10.000 


u 


Pop. 13837; 
^*8 cases ”, 

Aio,ooo 

'^cludinjj: citv^ 

I I I ■ ^ 




Total Pop., 83 465 818Cases * 38f^ 10,000. 


Map 2. — Distribution of cases by townships with rate per 10,000 of population. 


A and B to the north and F, G, H, I, and J to the south give 20, 
15, 19, 8, 0, 11, and 15 respectively and a combined average of 
only 14 per 10,000. 

The incidence rate of pellagra within the city of Spartanburg 




SILER, garrison: the EPIDEIMIOLOGY OF PELLAGRA 49 

was 49 per 10,000, considerably lower than the total rate (58) for 
township D, in which it is situated. The combined average^ rate 
of townships C, D, and E, exclusive of Spartanburg City, is 58 
against only 14 in the remaining townships. 

The population of the county may be still further divided geo- 
graphically into three parts: (1) the rural population; (2) the 
mill-village population; (3) the urban population of Spartanburg 
City. The rural population is found upon the farms and in eleven 
small towns, one of which has 1880 inhabitants, another 1101, 
and the remaining nine from 100 to 500 or 600. 

Approximately one-fourth of the population of the county live 
in the cotton-mill villages. There are twentj^-eight of these villages 
in the county, their individual population ranging from about 
200 to about 2000. Within the city of Spartanburg there are two 


Table II. — Rural, Mill-village, and Urban Distribution of Cases by Townshi])s. 


! 

1 

Total population. 

Rural population. i 

Mill-village population. 

ft) 

> 

o 

1 






1 




ft) 

tjo • 
a a 



rt 




d 


C3 


S o 




2 


tc 

i 



d 





o 


o 


ji 

o 


' 

c 

; _o 

a 

o 

_o 

c. 

o' 

^ 1 

s 

"o 

cu 

© 

u 

1 a c. 

*« 1 

s 

rt 

O 

V 

c 

a 

c; 

O 1 

tr. ! 

a ! 


o 

UJ 

a 

ft) 

1 CO’S 


§■ 

w 

1 

a 

V) 


c. 



■ W S 

K 

h 

! 

1 


Ph 


« 

Ph 

6 

« 

A " 

8,679 

17 

! 20 

8,179 

13 j 

15 

500 

4 

80 

Go 

B 

5,250 

8 

1 15 

4,650 

7 

13 

600 

1 

17 

4 

C 

12,073 

52 

43 

9,173 

17 

20 

2,900 

35 

121 1 

101 

D3 

13,837 

98 

1 71 

7,504 

21 

28 

6,333 

77 

, 120 

92 

E 

5,501 

32 

58 

2,751 

8 

29 

2,750 

24 

! 87 

1 58 

F 

6,874 

13 

19 

6,174 

8 

13 

700 

5 

' 71 

58 

G 

2,443 

2 

8 

2,443 

2 

8 

0 

0 

, 0 

H 

2,944 

0 

0 

2,944 

0 

0 

0 

0 

0 


I 

4,380 

5 

11 

3,580 

3 

8 

800 

2 

25 

17 

J 

3,967 

7 

18 

2,967 

1 4 

13 

1,000 

3 

1 30 

23 

City 

17,517 

1 85 

49 

(14,567<) 

, (43<) 

I (29') 

2,950 

42 

142 

! 113 

County 

83,465 

319 

38 

50,365 

! S3 

i 

18,533 

193 

' 104 

1 

' 88 


mill-villages, with a joint population of approximately 2950, the 
remaining 14,567 constituting the city population proper. Such 
a distribution of the population affords an opportunity to carry 
farther the analysis of the geographic distribution within the terri- 
tory of each township by considering separately the prevalence 
of the disease among the rural, urban, and mill-village population 
respectively. The results of this analysis are shown in Table II 
and are graphically displayed by Chart 1. 

With one exception, in each of the eight townships with a 
mill-village population, the prevalence of pellagra among the mill- 
villages is markedly in excess of its prevalence among the rural 
population, this excess ranging from 17 per 10,000 in township 
I to 101 per 10,000 in township C, and reaching even a still higher 

^ Exclusive of city. * City population exclusive of mill-village. 



50 


SILER, garrison: the epidemiology or pellagra 


figure (113) in the city of Spartanburg. In the county, as a whole, 
the mill-village population shows an excess of 50 per 1-0,000 over 
the total county average and of 88 per 10,000 over the rural dis- 
tricts alone. The apparent exception presented by township B, 
• in which the excess among the mill-village population was only 



Chart 1. 


4, disappears in view of the fact that the one mill in that township 
had been in operation only a month or so. The rate per 10,000 
in the urban population of Spartanburg City, exclusive of the mill- 
village population of the city, is about equal to the combined 
rate among the rural population of townships C, D, and E, exclusive 









SILER, garrison: the epidemiology of pellagra 51 

of their mill-village population, while the mill-village population in 
Spartanburg City (2950) shows 142 per 10,000, the maximum rate 
in our figures. 

Excluding bpth urban and mill-village population, and con- 
sidering the rural population alone, we find that the three townships 
C, D, and E still show a prevalence of pellagra twice that of the 
remainder of the county, the combined average rural rate for these 
townships being 24 per 10,000, while for the rural population of 
the remainder of the county it is only 12. 

There are two factors which may possibly offer an explanation 
of this difference. In the three townships (C, D, and E) showing 
the excessive rate, with a total population of 19,428, the mill- village 
population (9833) makes up 50 per cent, of the total population 
(excluding the city of Spartanburg), while in the remainder of the 
county, with a total population of 30,937, the mill-villages have 
a population of only 3600, or 12 per cent, of the whole. It might 
be supposed that a large mill-village population showing a rela- 
tively high prevalence would tend to increase the prevalence of 
the disease in the surrounding rural districts. 

The apparent fact that cases of pellagra are excessively prevalent 
in the mill-villages where the population is congested, suggests the 
question whether the congestion of population itself may not have 
an important influence upon the incidence of the disease. The 
average density of population for the county as a whole is 109 per 
square mile, while for the rural districts, exclusive of Spartanburg 
City, it is 86.5. For the rural population, exclusive of the mill- 
villages, it is 60.3. In the three townships C, D, and E, which show 
a striking excess of pellagra among the rural population compared 
with the rural population of the eight other townships, the density 
of rural population is 72 per square mile, and in the remaining town- 
ships it is only 56, a difference in density of 16 per square mile. 
While the greater density of population in townships C, D, and E 
might be a causative factor in the greater prevalence of pellagra 
in the rural population of those townships, the rate of prevalence 
does not vary strictly as the relative density of population in each 
township, though it shows some tendency to do so. 

Further evidence that density of population alone is not account- 
able for the greater prevalence of the disease in mill-villages is 
found within Spartanburg City itself. There the mill-villages, 
which are continuous with and an integral part of the city, present 
a rate of 142 per 10,000, whereas the remainder of the city popu- 
lation, living under approximately the same condition of congestion, 
gives only 29 per 10,000. Furthermore, the non-mill-village popula- 
tion within the city, with a density which is certainly over 3000 per 
square mile, shows almost exactly the same prevalence of pellagra 
per 10,000 as does the strietly rural population of the surrounding 
township, with only 90 inhabitants per square mile. 



52 SILER, garrison: the EPiDEiMIOLOGY OP PELLAGRA 

These figures would seem to indicate that while congestion of 
population may play a part in the prevalence of the disease, it 
alone does not explain the marked inequality of distribution between 
the mill-villages and the strictly rural population. 

VI. Racial Distribution. The distribution of the cases of 
pellagra in the county between the races presents a second marked 
inequality. While in South Carolina as a whole the number of 
whites and negroes is about equal, the negroes being slightly in 
excess, in Spartanburg County the whites predominate numerically 
in about the proportion of two to one, the actual figures being, 
whites 57,055, negroes 26,410 (Table III). The 57,055 whites gave 
257 cases of pellagra, or at the rate of 45 per 10,000; the 26,410 
negroes gave 25 cases of pellagra, or at the rate of 9.5 per 10,000. 
In other words, while whites are present in the population in the 
proportion of two whites to one negro, there are ten Avhite pellagrins 
to one negro pellagrin. 

One fact of fundamental importance in the racial comparison 
is the practical absence of negroes from the mill population. It 
follows that a more accurate comparison between the races can be 
made by comparing the rate of prevalence among negroes with 
the rate among whites, exclusive of the mill population. We have 
seen that the rate among the total population, exclusive of the 
mill-villages, was 18 per 10,000. Subtracting the negro population 
and the negro pellagrins we have remaining a white population, 
exclusive of mill-village population, of 38,522, which gave 97 cases 
of pellagra, or 25.2 per 10,000 against 9.5 per 10,000 among the 
negroes. In other words, in Spartanburg County the disease appears 
to be 4.7 times as prevalent among all whites as among negroes, 
and 2.6 times as prevalent among Avhites, exclusive of the cotton . 
mill-villages. 


Table III. — Distribution of Pellagrins among Whites and Negroes. 


1 

i 

Population. 

1 

Cases of 
pellagra. 

Rate per 10,000. 

Excess of whites 
over negroes per 
10,000 of popula- 
tion. 

1 

AH whites . ; 

57,055 1 

257 

45.0 

35.5 

Whites outside of 

^’iUages . . | 

38,522 

97 

1 

, 25.2 

15.7 

Negroes | 

2G,410 

25 

9.5 

1 


The racial incidence Avas carefully investigated Avith a view to 
determine whether the racial variation might be due to failure 
to discover cases of pellagra among negroes as readily as among 
whites. The practising physicians throughout the county Avere 
questioned as to the comparatiAm prevalence among the negroes 
in their partieular section, and as to its comparatiA^e preAAalence 



SILER, GARRISON; THE EPIDEMIOLOGY OF PELLAGRA 53 

in this race in the past. Without exception we were informed 
that pellagra in negroes was of comparatively infrequent occurrence. 
In this connection it is well to state that many of these physicians 
have lived and practised medicine in the same place for many years; 
that they are personally acquainted with practically the entire 
population in their particular field of work, both whites and negroes, 
and that they are in general thoroughly capable of correctly diag- 
nosticating the disease. 

The two colored physicians in Spartanburg were closely ques- 
tioned as to the occurrence of pellagra in their practice at present 
and in the past, and the cases cited by them are included in our 
statistics. Furthermore, the information furnished by them rela- 
tive to the occurrence of cases in the past is in accord with these 
statistics. When negroes suffering with pellagra were visited a 
particular effort Avas made to secure from them information as 
to the occurrence of the disease in others of their own race. A 
number of names Avere secured in this Avay, and many negroes sus- 
pected of liaAdng the disease Avere visited. Many of the planters 
OAvning large plantations and having as tenants or laborers a large 
number of negroes Avere closely questioned as to the prevalence 
of the disease, and in some instances canvasses Avere made. Not- 
Avithstanding the efforts made to discover the disease in negroes, 
it was impossible to find more than tAventy-five cases. 

It is not believed that the number of cases overlooked could 
materially alter the relative incidence of nearly fiA'^e cases in Avhites 
to one in negroes, and the racial variation is evidently a real one, 
though it may possibly be explained in part by the absence of 
negroes from the mill-village population, Avhich, as Ave have seen, 
shows a marked excess of pellagra compared Avith the remainder 
of the white population. 


Table IV. — Racial Distribution of Population and Racial Distribution of 
Pellagra with Percentages. 


Populution statistics.^ 

Pellagra statistics. 

State. 

White. 

Negro. 

AVhite. 

• Pellagra 
per 10,000 
Negro. popu. 

lation. 

Number. , % 

Number. 

% 

No. 

% 

No. % W. 

N. 

A^irginia .... 
North Carolina . 
South Carolina . 
Georgia .... 
Kentucky 

Alabama .... 
Mississippi 

Louisiana 

1.389.809 
1,500,513 

097,162 

1.431.810 
2,027,951 
1,228,832 

786,119 

941,080 

67.4 

65.0 

44.8 

54.9 

55.0 

57.5 

43.7 

50.8 

671,096 

097.843 

835.843 
1,176,987 

261,650 

908,282 

1,009,487 

713,874 

32.6 

31.6 
55.2 

45.1 

11.4 

42.4 

50.6 

43.1 

476 

1744 

1129 

3127 

442 

11.38 

1387 

338 

76 

81 

71 

80 

92 

58 

55 

56 

i 

152 24 3 

407 19 12 

471 29 ^ 16 

741 , 20 22 

39 1 8 1 2 

813 ' 42 ; 9 

1156 , 45 , 18 

209 44 ! 4 

2 

6 

6 

6 

4 

9 
11 
‘ 4 


‘ Population statistics are those of the Thirteenth Census (1910). The pellasra statistics 
were compiled from those reported by Lavinder in reprints from Weekly Public Health Reports. 



54 SILEK, garrison; the epidemiology of pellagra 

Table No. IV is an analysis of population by race, and of the 
incidence of pellagra by race for eight Southern States. The pellagra 
statistics in this table were secured by correspondence and, as 
Lavinder states, are very incomplete. 

In Spartanburg County there is a marked difference in racial 
incidence, but any suggestion that this depends upon the factor of 
race alone may seriously be questioned. In Table IV it may be seen 
that the case incidence in the two races in the States of Alabama 
and Louisiana shows little difference; while in South Carolina and 
Georgia, and to a less extent in North Carolina, there is a marked 
preponderance in whites. It is possible that industrial conditions 
in these States account largely for this variation. 

VII. Sex Distribution. The population of the county is 
divided practically equally between males and females, the females 
being only 27 in excess. The total male population of 41,719 
gave 71 cases of pellagra, or at the rate of 17 per 10,000. The female 
population gave 211 cases, or at the rate of 60.5 per 10,000 (Table V). 
In other words, pellagra appears nearlj'^ three times more frequently 
among females than among males. Among the white population 
alone this proportion between males and females remains about the 
same, while among the negroes the relative prevalence among males 
and females is nearly four females to one male. This inequality 
between the sexes is brought out more strikingly and in greater 
detail if the figures are analyzed by dividing the population accord- 
ing to age. 

Table V. — Distribution by Sex. 



Number in 

Cases of 


Excess per 10,000 


population.® 

pellagra. 

xvuvt? pui IU|UUU« 

among females. 

Whites: Male 

28,758 

66 

22.95 


Female . 

28.290 

191 

67.5 

44.5 

Negroes: Male 

12,958 

5 

3.9 


Female . 

13,452 

20 

14.9 

11.0 

Both races: Male 

41,710 

71 

17.0 


Female . 

41,742 

211 

50.5 

33.5 

Total population . ' 

I 

83,458® 

282 

.33.8 



Table VI. — Age Distribution of Two Hundred and Eighty-two Cases. 


Age. 

1 

Total population.’ 1 

1 

Cases of pellagra. 

Rate per 10,000. 

0 to 5 

15,194 

21 

10.8 

6 to 9 1 

8,852 ! 

22 1 

1 

24.9 

10 to 19 

21,860 

28 

12.8 

20 to 44 j 

26,239 

158 

60.2 

45+ 

j 11,161 

53 

47.5 


6 Exclusive of 4 Indians, 2 Chinese, and 1 Japanese. 
’■ Exclusive of 159 persons of unknoivn age. 


SILER, gar^iison; the epidemiology of pellagra 55 

VIII. Age Distribution. First, considering the prevalence of 
pellagra aecording to age, without reference to sex, we find the 
inequalities shown in Table VI, and graphically presented in Chart 2. 



Chart 2. — Total numbei of casea ui each decade. 


^ In this and the following tables dealing with age distribution, 
in which the prevalence of pellagra is expressed in rate per 10,000 
of the population, our age groups are necessarily made to conform 
to the age statistics for the population of Spartanburg County 
which could be secured from the United States Census Bureau— 
namely, the population of the county under six years of age, from 
six to nine years, ten to nineteen years, twenty to forty-four years, 
and forty-five years or older. The actual number of cases in these 
groups means little because of the wide difference in the size of 
t le groups, both with regard to the number of years and the number 




56 SILER, GARRISON; THE EPIDEMIOLOGY OP PELLAGRA 

of individuals concerned. A striking excess in tlie rate of preval- 
ence is apparent in the group tAventy to forty-four years of age 
(60.2 per 10,000). The rate among those over forty-four years of 
age is much higher than in any other group excepting that between 
tiventy and forty-four years. These two groups taken together, 
that is, the entire population over nineteen years of age compared 
with the entire population under twenty years of age gives the 
following result: Twenty years and older, 211 cases, or 56.4 per 
10,000; nineteen j-ears and younger, 71 cases, or 15.5 per 10,000. 

Dividing the younger group we find that children under ten 
years of age gave a total of 43 cases, or 17.9 cases per 10,000; 
those from ten to nineteen years of age gave 28 cases, or 12.8 per 
10,000. Furthermore, this higher prevalence for children under ten 
years is found entirely among the children between the ages of five 
and ten years who alone gave a rate of 24.9 per 10,000, while the 
younger group under five years of age gives only 10.8 per 10,000, 
the lowest rate found in any group. 

In Chart 2 the distribution of pellagra by the number of cases in 
each age group is shoivn, dividing the eases into age decades. By 
comparing this chart with Table VI it is evident that the curve 
would be considerably modified if it expressed the rate per 10,000 
of population instead of the actual number of cases in our figures. 
The prevalence among children under ten years would not be quite 
so high compared with that in other groups. The relative prevalence 
in groups over forty years would be higher. The two groups of 
from twenty to forty years would still shoAV a striking excess over 
all other decades. It may be said here that the marked fall in the 
prevalence of pellagra in the groups ten to nineteen years appears 
throughout our statistics, and will come out strikingly in the 
consideration of the family distribution of the disease. 

IX. Distribution by Age and Sex. It is important to as- 
certain Avhether the excessive prevalence of pellagra among females 
holds in all ages of the population, and whether the excessive 
prevalence found in certain age groups, notably those from twenty 
to forty-five j^ears, is to be found among both males and females. 
Referring to Table VII it may be seen that the excess among females 
is not the same among all ages of the population, but is confined 
largely to those between the ages of tiventy and forty-four years. 
Further, under ten years of age males and females show practically 
the same prevalence of pellagra. From ten to nineteen years the 
females show a rate a little over twice that of the males; in the 
large group of from twenty to forty-four years the females shoAV 
a rate per 10,000 over nine times greater than the male rate. 
Among the population of forty-five years and over the distribution 
between the sexes is again nearly equal. 

These cases have been further analyzed by decades, with the 
result as represented graphically by curves in Chart 3. These 
curves express actual number of cases. 



SILER,- garrison: the epidemiology of. pellagra 57 


Table VII. — Distribution by Age and Sex. 


Age. 

Sex. 

Population. 

Number 
of cases. 

Rate per 10,000. 

Excess per 
10,000. 

Under 5 

M. 

7,763 

10 

12.9 



F. 

7,431 

11 

14.8 

1.9 

a to 9 

M. 

4,490 

12 

27.0 



F. 

4,364 

12 

27.5 

O.o 

10 to 19 

M. 

10,906 

7 

6.4 



F. 

10,954 

16 

14.0 

S.2 

20 to 44 

M. 

12,822 

16 

12.5 



F. 

13,417 

14S 

110.3 

9V . S 

Over 44 

M. 

5,652 

25 

44.2 



F. 

5,509 

27 

49.0 

4.S 



The fall in the curve in the second decade of life is present for 
both sexes, but is more marked for males; Thereafter the male 
curve continues to fall, whereas the female curve rises to its highest 




58 SILER, garrison: the epidemiology of pellagra 


point in the following decade (twenty-one to thirty years), drops 
slightly among women of thirty-one to forty years, then falls 
abruptly in the next decade (forty-one to fifty years) to a point 
somewhat below both males and females under ten years. In the 
decade of from fifty-one to sixty years the female curve continues 
to fall, and for the first time descends below the male curve, which 
shows a slight rise. Thereafter the number of cases is small and 
the two curves fall together. 

The data expressed in Table VII and Chart 3 may be summarized 
as follows: Pellagra appears to be about equally prevalent among 
males and females under ten years of age and over forty-five years. 
Males alone show the highest prevalence in children under ten 
years. Females show a strikingly higher prevalence in the two 
decades of twenty to thirty and thirty to forty years than does 
either sex in any other decade. 

Table VIII indicates in a general way that both whites and negroes 
separately show practically the same inequalities in the distribution 
of pellagra between the sexes in the different age groups, as has 
been shown in considering both races together. Any closer analysis 
of the figures for the two races is unsatisfactory, owing to the small 
number of negro cases in each age group. 


Table VIII. — Race, Age, and Sex Incidence (Two Hundred and Eighty-two 

Cases). 



Wliitcs, 257 cases. 

Negroes, 

25 cases. 

Age. 





Male. 

Female. 

Male. 

Female, 


Under 1 to 5 

9 

11 

1 

0 

Under 6 to 10 

12 

11 

0 

1 

Under 11 to 20 

9 

14 

0 

3 

Under 21 to 30 

4 

05 

2 

11 

Under 31 to 40 

0 

5G 

1 

3 

Under 41 to 50 

G 

20 

0 

0 

Under 51 to 60 

14 

9 

0 

0 

Under G1 to 70 

4 

5 

1 

1 

Under 71 to 80 

1 

0 

0 

0 

Under 81 to 90 . 

1 

0 

0 

1 

Totals 

C6 

191 

5 

20 


While it is not proposed to enter into any extensive comparative 
studies in this preliminary report, there are certain data upon the 
age and sex distribution of pellagra in this country which present 
an interesting parallel with the figures for Spartanburg County. 

Chart 4 represents by curves based on actual number of cases 
the age and sex distribution of 164 cases of pellagra, 99 of which 
were reported by Mizell,® of Georgia, and 65 by Tucker,® of Virginia. 

® From paper read at the Second Triennial Aleeting of the National Association for the Study 
of Pellagra, Columbia, S. C., October 3, 1912. 

• Beverley R. Tucker, A Discussion of Pellagra, with Remarks on Sixty-six Cases 

Occurring Outside of Institution.^, Old Dominion Jour. Med. and Surg., April, 7911, vol. xii. No. 4. 



SILERj GARRISON; THE EPIDE^IIOLOGY OF PELLAGRA OJ 

Chart 5 shows mortality rates for the State of Texas. This 
chart was furnished to us by Dr. H. K. Beall, of Fort Worth, 
Texas, who first directed attention to the inequalities of distri- 
bution by age in males and in females. 

Chart 6 is based upon death reports of pellagra in Alabama 
between June, 1909, and December, 1912. These reports cover a 
total of 1148 cases during this period. The data were kindly 
supplied by Dr. W. H. Sanders and Dr. H. G. Perry, of the Alabama 
State Board of Health.’^^ 


AG£ AKD SEX IHCIDEKCE IK KON-IKSTITOTIOHAL CASES. 

( l&A Cases) 


Ho. 

Under 1 
to 

10 vrs. 

11 to 20 

Tears 

21 to SO 

31 to 40 

41 to 50 

SI to 60 

61 to 70 

71 to 80 


SO 

45 

40 

35 

SO 

25 

20 

15 

10 

5 

0 



















r ' 








( 








1 

/ 

, 







1 


\ 





1 

1 



\ 

\ 





1 



V. 





1 

/ 



'v 

\ 

% 




/ 

/ 




\ 

N 

\ 


f 

- v 










— . 

Males ■ ■ 

Females — 



Chart 4. — Age and sex incidence in non-institutional cases. 


Chart 7 presents a graphic representation of mortality rates 
for pellagra in the State of North Carolina for 1911 and 1912. 
We have to thank the health authorities of North Carolina for the 
information on which this chart is based.^^ 

The data from these five sources are all the statistics available 
to us at the present time which lend themselves to a comparison 
with our own figures regarding age and sex distribution. It should 
be noted that the curves in Chart 4, like our own, are based on 
morbiditj'' statistics, while Charts 5, 6, and 7 are based upon 
death re^iorts. 


“ Personal communication. 


« Ibid. 


« Ibid. 




60 SILER, garrison: the epidemiology of pellagra 

A comparison of the four charts shows considerable variation 
in both the male and the female curves in different age groups. 



They all agree, however, in showing a strikingly excessive pre- 
valence among females of middle age and a comparative equality 









SILER, garrison: the epidemiology of pellagra bl 

of distribution between males and females in childhood and among 
people of advanced age. 



Chaht 6. — Mortality rates for the State of Alabama by ago and Rex. 


X. Distribution by Occupation. The consideration of the 
relationship between occupation and the incidence of pellagra in 
Spartanburg County resolves itself' almost entirelj^ into a dis- 

- VOL. 14G, NO. 1.— JI7LT, 1913 3 



62 SILER, garrison: the epidemiologt of pellagra 

cussion of the relative prevalence of the disease among field laborers, 
workers in the cotton-mills, and those engaged in housework. 
Only a few scattered cases gave other employment. The actual 
data with regard to occupation obtained from 234 cases of pellagra 
is set forth in Table IX: 110 (47 per cent.) gave housework as 
their occupation exclusively; 14 others (6 per cent.) gave house- 
work as their chief employment; 16 (6.8 per cent.) were employed 
in housework part of the time, working the remainder of the 
time in the mills; 18 (7.7 per cent.) worked alternately about the 
house and in the fields. Thus a total of 158 (67.5 per cent.) of 


VOMH OSOLIRA KOSTALITT STATISTICS (im k 1912) 
f.Ct AJT> SEX. 310 CASES. 




BSSB 

VBZI 






tmtmm 











B 

B 

B 

B 






B 

B 


B 






B 

B 

\ 







/ 

/ 


B 







B 



\ 






/ 

1 . 

n 


\ 

\ 






t 

1 



B 

B 




/ 





B 




■ 


B 

B 


B 




■ 

B 

B 


B 


\\ 

B 


B 

B 

B 


B 


B 

B 



B 

B 





B 


H&Iqs 

Te£«lea 


Ghaut 7. — ^North Carolina mortality statistics during 1911 and 1012. 


the 234 cases, were employed in household work within the home 
for at least a fair portion of their time. These figures mean little 
more than what has already been shown by the age and sex dis- 
tribution of the disease — ^namely, that it is excessively prevalent 
among adult females the great majority of whom are employed in 
housework. There is one further indication, however, that pellagra 
has a much higher prevalence among the adult females of the 
mill-villages who are occupied as housewives than among those 
who work in the mills, and this point may be more closely examinerl 
by considering the occupational distribution of pellagra in the mill 
population alone. 







SILER, garrison: the epidemiology of pellagra 


63 


Table EX. — Distribution of Two Hundred and Thirty-four Cases of Pellagra 

by Occupations. 


Occupation. 

Males. 

Females. 

Both sexes. 

Per cent, of 
total. 

Farmers 

14 


14 

6.0 

Field work and housework . 


is 

18 

7.7 

Mill work exclusively 

2i 

20 

41 

17,5 

Mill work, some housework . 


16 

16 

6.8 

Housework exclusively . 


110 

110 

47.0 

Housework chiefly, some mill 
work 


14 

'l4 

6.0 

Scattering’^ 

9 

3 

12 

5.1 

No occupation .... 

2 

7 

9 

3.8 


There are available for this study 121 cases of pellagra of work- 
ing age residing in mill-villages. Of these, 24 were males and 97 
females; 21 (87.5 per cent.) of the 24 males were mill operatives], 
Of the 97 females, 12 (only 12.37 per cent.) worked in the mills 
exclusively; 16 additional female cases worked in the mills the 
greater part of the time, making a total of 28 female mill workers 
(or 28.86 per cent.) of the 97. 

46, or very nearly half (47.42 per cent.) of the 97 women did 
no ^ mill work, devoting themselves to housework exclusively; 
while 14 others were chiefly employed in housework, going to the 
mills only occasionally, making a total of 60 houseworkers, or 
68.85 per cent, of the female pellagrins of working age living in 
the mill-villages. 

We have no actual statistics regarding the proportion of males 
and females among mill operatives. It would seem perfectly'’ safe 
to say that there are at least as many females as males, the pro- 
babilities being that they are in a considerable majority. As a 
rule, female operatives are preferred by the mill operators. Assum- 
ing equality between the sexes among mill workers, as may surely 
be done \yith safety, the data above presented has a highly impor- 
tant significance, in that it shows a nearly equal prevalence of 
pellagra in males and females who are employed in the mills as 
operatives namely, 17 males and 12 females — if we include only 
those women doing mill work exclusively, and 28 females if we 
include the 16 who gave mill work as their chief but not exclusive 
occupation. This comparative equality as regards the prevalence 
o pellagra between the sexes among mill operatives is in striking 
contrast to the inequality between adult males and females in our 
sex statistics for the population as a whole, and is very closely in 
harmony with what is known of sex distribution in institutional 

cases where a diflerence in prevalence between the sexes is absent 
or slight. 

In comparing the mill-village population with the rural popu- 


morchanta. two dressmakers, one w.as employed in each of the following 
tocher c-'^rpenter. butcher, clerk, railroad fireman, day laborer, school 



64 SILER, garrison: the epidemiology of pellagra 

lation as regards the prevalence of pellagra, we found the disease 
nearly seven times as prevalent in the mill-villages as in the rural 
districts, the actual rate of prevalence in the mill population being 
104 per 10,000. Out of the total mill-village population of approxi- 
mately 19,000, about one-half, or 9500, are actually employed in 
the mills. Among these mill operatives we have 57 cases of pellagra, 
including those patients who gave mill work as their chief but not 
exclusive occupation. These 57 cases give a rate of 60 per 10,000 
among actual mill operatives, against 104 per 10,000 for the total 
mill-village population. The 41 patients giving a history of mill 
work exclusively present a rate of only 43.2 per 10,000. These 
figures seem to indicate that the excessive prevalence of pellagra 
in the mill- village population is not found among those who actually 
work in the mills, but among the women engaged in the day about 
the houses, and the children who are at home with them. 

"While children under working age do not form a part of an occu- 
pational study, it may well be noted in this connection that 30 
mill-village children under ten years of age had pellagra. These 
cases added to the 60 adult females in the mill-villages engaged 
in housework exclusively make a total of 90 cases of pellagra in 
the mill-village population of the county, which by occupation 
were about the dwellings during the day, against 57 cases among 
the population engaged in mill work. The 57 operatives give a 
rate of 60 per 10,000 for the half of the mill-village population 
which works in the mills. The 90 houseworkers and children give 
a rate of 94.7 per 10,000. 

XI. Distribution of Cases in Families. 316 cases of pellagra 
are available in our data for a study of family and household 
relationships, and these cases represent 223 families, an average 
of 1.42 cases of pellagra per family. An analysis of the family 
distribution is given in Table X. About half the total number 
of cases occurred singly in families, and about one-fourth of the 
total number occurred two to a family. Of the total number 
of families with pellagra (223) nearly three-fourths (160) had but 
one case, and nearly one-fifth gave but two cases. Nearly one- 
tenth of the families gave 3, 4, or 5 cases. 

In view of the inequalities found in the prevalence of pellagra 
in the two sexes, and at different ages, an attempt has been made 
to discover whether the sex and age distribution differs among 
eases which occur singly in families from the distribution among 
cases occurring two or more to a familj’’ — ^in other words, to deter- 
mine whether cases developing singly in families are apt to be of 
any particular age or sex, and to differ in these respects from multi- 
ple family cases. For this purpose, 294 cases for which age and 
sex statistics are available have been charted (Chart 8) by age 
periods of five years each — cases occurring singly in families being 
represented by a solid line, and cases oceurring two or more to 



SILER, garrison; the epidemiology of pellagra 


65 


a family by a broken line. The upper two curves represent male 
cases alone; the middle curves, females alone; and the lower 
curves, the two sexes combined. The curves represent the per- 
centage of the total 294 cases and not the actual number of cases 
in each group. Accordingly, the solid line and the broken line would 
coincide wherever the same condition of distribution exists between 
single cases and cases occurring two or more to the family. 


Table X. — Distribution of Pellagra in Families. 



Number of 
families. 

Number of 
cases. 

1 

Percentage of j 
total number I 
of families. 

Percentage of 
total number 
of cases. 

One case to one family . . ! 

160 1 

160 

71.7 

50.6 

Two cases to one family . 

42 

‘ 84 

IS.S 

26.6 

Three cases to one family 

14 . 

42 

6.3 

13.3 

Four cases to one family . | 

5 

20 

2.3 

6.3 

Five eases to oue family . . j 

2 

10 

0.9 

3.2 

Total with more than onel 
case to one family . 

63 1 

156 

i 28.3 

1 

49.4 


The most striking inequality between the two curves is present 
among children under ten years of age. Not only is the curve for 
multiple family cases higher than the curve for single cases in both 
males and females, but for males alone and for the combined sexes 
it goes higher among children under ten years than in any other 
age group. _ In this respect it presents a striking contrast to the 
curve for single family cases and to our general age distribution. 
It is remarkable, further, that this excessive prevalence in multiple 
family cases is much greater among males than among females, 
especially in the younger group of children under six years of age. 
Among cases occurring singly in families the curve never goes above 
6 per cent, in any age group under twenty years among males, 
females, or the sexes combined. These facts seem to show that 
where single cases of pellagra occur in families it is rarely children 
under ten years who are the ones attacked. Among families with 
more than one case, however, children under ten years form a 
higher percentage of the cases than does any other decade. Among 
families with but one case it Avould appear that the two decades 
from twenty-one to forty years give the great majority of cases 
among females, while among males more single cases occur among 
those over fifty years. 

^ When considering the subject of age and sex distribution, atten- 
tion was called to the striking fall of prevalence apparent among 
persons from eleven to twenty years old. Inspection of the curves 
^ shows this fall to be confined almost entirely to cases 
which occur two or more per family, the indication being that 


G6 SILER, garrison; the epidemiology of pellagra 

isolated cases in families are as apt to arise among individuals 
from eleven to twenty years of age as among children under eleven 
years. 

The Age and Sex Distribution of Pellagra in Families 
with a single case and in Famillles with two or more cases 


SlDglc ease* rtf t«p| Ij ■ ■■ - ■— - ■ Msltlpt* ca«ts ftvlly 



Chaht 8. 

It is not considered advisable to proceed farther at the present 
time in an analysis of the family relationships of pellagrins. Such 
further investigation would cariA' us into a study of each individual 
family, the actual sequence of cases in each family, and, further- 
more, would introduce the whole subject of household association 
and its significance with regard to the family relationship. As 
yet our data are not sufficiently complete to make such a study in 
a satisfactory manner. It may be said, however, that while there 
is some evidence in our preliminary investigation that family 
relationship iier se does seem to have some influence upon the 
incidence of pellagra, there are stronger indications that household 
association is a more important factor in the distribution of the 
disease. 


(To be concluded.) 



BAER: INFLAMMATION IN THE ANTERIOR OCULAR SEGMENT 67 


THE DIAGNOSIS OF INFLAMMATION IN THE ANTERIOR 
OCULAR SEGMENT.! 

By B. F. Baer, Jr., B.S., M-D-, 

ASSISTANT OPHTHALMIC SURGEON, EVE DISPENSARY OF THE HOSPITAL OF THE UNIVERSITY 
OF PENNSYLVANIA, PHILADELPHIA. 


The ability to diagnosticate ocular inflammations is of the 
utmost importance. Delay in instituting treatment may result in 
irreparable damage to the ocular tissues, and faulty diagnosis may 
be followed by treatment fatal to vision. Far too often has the 
sight of a glaucomatous eye been destroyed by the instillation 
of atropine under the impression that the disease was iritis. 

The purpose of this paper is to facilitate diagnosis by calling 
attention to the signs indicative of the forms of inflammation 
likely to be encountered in one’s daily work. 

Inflammations in the anterior ocular segment may be divided 
into those of the conjunctiva, the cornea, the iris and ciliary body, 
glaucoma, and inflammations consecutive to violence. 

These inflammations have as the most noticeable feature vascular 
injection. The vessels participating in this injection are either 
the posterior conjunctival or the anterior ciliary, and depending 
upon which of these systems is congested we speak of conjunctival 
or ciliary injection. Conjunctival injection appears as a superficial 
network of bright red bloodvessels whose position in the conjunc- 
ti'\'^a is demonstrated by the fact that movement of this membrane 
causes a corresponding change in position of these vessels. The 
vessels can be individually distinguished. This is the injection 
of conjunctivitis. Ciliary injection appears as a dark red or vio- 
laceous zone surrounding the cornea, and its position beneath the 
conjunctiva is demonstrated by the fact that movement of this 
membrane does not result in a change of position of this zone. 
Instead of the individual vessels being distinguishable there is a 
general diffuse redness. This is the characteristic injection of 
inflammation of the cornea and iris and ciliary body. 

Acute contagious conjunctivitis, or pink eye, is the classic type 
of conjunctivitis. The symptoms, conjunctival injection, lachry- 
mation, photophobia, and mucopurulent discharge together with 
some burning and itching of the eyes, are those which exist with 
slight variations in all forms of conjunctivitis. This form of con- 
junctivitis responds readily to argyrol and boric acid flushings, 
and is of interest because of its epidemic tendency, one case fre- 
quently being responsible for the spread of the disease through an 
entire school. 


' Read before the staff of 
October 7, 1912. 


the Physicians’ and Surgeons' Hospitu), Wilmington, Delaware, 



68 BAER: INTLAMMATIOK IN’ THE AKTERIOR OCULAR SEGMENT 


Gonorrheal conjunctmtis, of wiiich there is the adult form and 
that seen in the newborn, is a destructive disease which beginning as 
conjunctivitis may rapidly extend to the adjacent tissues, producing 
in a few days even a purulent panophthalmitis. Thanks to Crede 
this is now a rare disease in the newborn. By the use of silver 
nitrate instillations in the eyes of all infants born in the Leipsic 
Lying-in Asylum, Crede reduced the percentage of ophthalmia 
neonatorum from 10.8 to between 0.1 and 0.2. The benefits 
obtained from this treatment are so immeasurable that Crede’s 
prophylactic treatment cannot be too often retold. During the 
first bath the eyes are cleansed with pure water — not that of the 
bath — and cotton, and one drop of a 2 per cent, silver nitrate 
solution instilled into each eye. Since ophthalmia neonatorum 
may originate from other than gonorrheal organisms, this treat- 
ment should be used in all newborn infants. Most of the cases of 
gonorrheal conjunctuntis we now see belong to the adult form, 
and occur in patients suffering with gonorrheal uretlmitis or in 
those who have become infected through using the towels and 
linen pre\*iously used by gonorrheal subjects. After an incubation 
period varying from two or forty-eight hours the lids become red 
and swollen, often to such a degree that they can only with difficulty 
be separated. The tarsal and ocular conjunctivas are intensely 
edematous, and have a rough, granular appearance. The swelling 
of the ocular conjunctiva ends abruptly at the margin of the cornea, 
and the cornea appears as if bung in a pit. The secretion during 
this stage is serous and tinged with blood, having much the appear- 
ance of beef juice. After tw'o or three days the secretion becomes 
purulent, and the chemosis and swelling begin to subside. The 
most dreaded complication is involvement of the cornea, resulting 
in ulceration and even panophthalmitis. Treatment must first be 
directed toward the prevention of the infection of the second eye 
if it is still uninfected. This is done by hermetically sealing this 
eye with a w'atch-glass strapped down with adhesive tape. Treat- 
ment of the infected eye consists of cold compresses, instillations 
of argyrol, and frequent cleansing of the eyes with 1 to 5000 potas-- 
sium permanganate solution. As soon as pus begins to flow from 
the eyes and the swelling in the lids is sufficiently reduced to allow 
of their eversion the tarsal conjunctiva must be painted with a 
2 per cent, silver nitrate solution twice dailj’’, care being taken 
that the solution does not come in contact with the cornea. When 
the cornea appears cloudy or its surface dulled, hot compresses 
must be substituted for the cold, in the effort to stimulate corneal 
nutrition. Gonorrheal opthalmia is so contagious that the most 
rigid isolation of these patients is necessary. While it is rare to find 
an infection of the conjunctiva showing such violent inflammation 
as that seen following a gonococcal invasion, other organisms w'ill 
sometimes give rise to a condition w'hich in the early .stages resembles 



BAER: INFLAIMMATION IN THE ANTERIOR OCULAR SEGMENT 69 

gonorrheal conjunctivitis. A resort to microscopic examination 
will differentiate these conditions, as the gonococcus is present if 
the inflammation is due to its influence. 

In scrofulous children, phlyctenular conjunctivitis is a common 
disorder. This disease shows, in addition to the usual signs of 
conjunctivitis, small reddish tumefactions, about the size of a 
split pea or smaller, around the margin of the cornea, and often 
in the cornea itself. After two or three daj^s these phlyctenules 
break down into small ulcers, which rapidly heal over, only to be 
succeeded by new crops, ‘the process continuing over weeks and 
months. If, in the cornea, they leave after healing permanent 
opacities, which when central materially interfere with vision. 
Treatment of phlyctenular conjunctivitis, or if the cornea is 
involved, phlyctenular keratitis, should aim toward the upbuilding 
of the general system. The local treatment consists of atropine for 
its sedative effect, frequent cleansing of the eyes, and protection of 
the eye from light by the use of dark glasses. 

Inflammation of the cornea, keratitis, shows in addition to 
ciliary injection some change in the polish and evenness of the 
surface, or some loss in the transparency of the cornea. Superficial 
lesions of the cornea, for example, a phlyctenular or other ulcer, 
appear as spots in which the lustre and evenness of the cornea 
are lost, the area being somewhat depressed below the general 
surface. If fluorescin is dropped into such an eye the spots stain 
a bright green. A whitish halo of corneal infiltration surrounds 
each of these areas. Change in the transparency of the cornea is 
due to change in the deeper layers, such, for example, as is seen in 
interstitial keratitis. Were one to examine the eyes of the little 
victim of congenital syphilis, with his large forehead, deeply lin^d 
face, and weeping eyes, gray or whitish spots deeply situated in 
the generally cloudy cornea could be seen ; or if these spots were so 
numerous as to have become confluent, the cornea would have a 
general ground-glass appearance, often so dense as to obscure the 
underlying iris. Closer examination of these eyes would show 
vascular twigs, branching broom-like, appearing suddenly from 
beneath the corneal limbus, and penetrating toward the pupillary 
area. 

In iritis and inflammation of the ciliary body, cyclitis, the char- 
acteristic changes are naturally in these tissues, and, owing to 
their location, changes occur also in the aqueous and anterior 
chamber. The iris is hyperemic and swollen, and as a result the 
pupil is small and non-responsive to light. Inflammatory exudates 
in tlie iris tissue result in change of color of the iris, readily observed 
by comparison with its fellow iris. The aqueous is turbid, and 
frequently deposits are seen on the posterior surface of the cornea 
as small dark-colored points over the lower half of Descemet’s 
membrane. The pupillary margin of the iris, where it lies in con- 



70 BAER: INFLAMMATION IN THE ANTERIOR OCULAR SEGAIENT 

tact with the anterior lens capsule, becomes glued to this structure 
at various points. These points of attachment, posterior synechia, 
upon dilatation of the pupil with atropin, become evident, as a 
result of which the pupil appears irregularly round, the attached 
points not yielding to the drug action. Aside from traumatism, 
iritis generally arises as a result of some constitutional condi- 
tion, of which syphilis and rheumatism are the most frequent. 
Tuberculosis, gonorrhea, metabolic disturbances, and acute infec- 
tious fevers are responsible for a certain proportion of the cases. 
Treatment must therefore be directed against the constitutional 
condition. Locally, antiphlogistic measures and atropine should 
be employed. Potassium iodide and mercury facilitate absorption 
of the inflammatory exudates. 

When there is a disproportion between the inflow and outflow of 
the circulating fluids in the eye, the inflow being in excess, there is 
a rise in intra-ocular tension. Such a condition is called glaucoma. 
The symptoms of glaucoma, including cupping of the nerve head 
and loss of sight, originate as a consequence of this elevation of 
tension. 

Beginning with gradual elevation of tension, lasting over months, 
during which time the patient has attacks of cloudy vision, dull 
headache, sees colored rings around the street lights (halo vision), 
the attacks becoming more frequent and severe with the progress 
of the disease, this prodromal stage finally culminates in an acute 
glaucomatous attack, with violent pain in the eye, face, and jaws, 
vomiting and fever, sudden and almost complete loss of vision, 
injection of the eye, and a dilatation and rigidity of the pupil. The 
tension at this time, if tested, would be found to be extremely 
high. With these symptoms the trouble can be easily recognized, 
yet these attacks are sometimes mistaken for hemicrania. Such 
an attack may result in blindness in a few hours or, as more usually 
happens, the tension gradually goes down and the irritating signs 
disappear, leaving as a permanent aftermath slight reduction in 
visual acuity. A few weeks later, with a gradual elevation of the 
tension, a second attack supervenes, only to be succeeded by future 
attacks, each of which leaves the eye more permanently impaired, 
until finally it is stony hard, totally blind, and the seat of constant 
severe pain. This so-called acute inflammatory glaucoma is a rare 
condition. 

In chronic inflammatory glaucoma, the more usual form, the 
eye passes gradually from the prodromal stage into a glaucomatous 
condition, with increasing redness of the globe, increasing dilatation 
of the pupil, and the iris slowly becoming atrophic. The tension 
rises slowly, but persistently, and at the same time the visual acuity 
recedes. The attack is not so severe as occurs in acute glaucoma, 
although the ultimate result of the disease is the same in both 
forms. Chronic inflammatory glaucoma is sometimes mistaken 



baer: inflammation in the anterior ocular segment il 

for iritis, and unfortunately treated with atropine. One of my 
preceptors in opthalmology not long ago told me of the following 
experience. A medical practioner brought a patient to him who 
for the previous three weeks had been using, with no apparent 
benefit, medicines prescribed for conjunctivitis. The inflammation 
happened to be iritis, and promptly subsided under proper treat- 
ment. The mental process at work in the mind of this practitioner 
must have been as follows; if a case when treated as conjunctivitis 
does not get well, try atropine, it may be iritis; for not long after' 
he called in the same consultant to ascertain why, in another case, 
atropine was not yielding the desired result. This case was, unfor- 
tunately, chronic inflammatory glaucoma, and when first seen by 
the oculist the sight was entirely obliterated. I have encountered 
three cases of a similar nature, in each of which the sight was 
lost. 

The uveal tract (iris, cilia y body, and choroid) supplies the 
ocular fluids, and Schlemm’s canal is the channel through which 
the excess is carried off. In order to reach Schlemm’s canal these 
fluids must first filter through the ligamentum pectinatum, a 
layer of loose cellular tissue which extends from the root of the iris 
forward to the point of junction of the sclera ahd cornea in the 
filtration angle. Dilatation of the pupil allows the iris to fill in 
this angle and overlie the ligamentum pectinatum, thus impeding 
the outflow of the ocular fluids. This happens in glaucoma, and 
if in such a condition further dilatation of the pupil is induced, as 
bj^ the instillation of atropine, the filtration of the ocular fluids 
is further impeded. 

Still a third form of glaucoma, chronic non-inflammatory, has, as 
can be inferred from its name, little or no inflammatory reaction, 
the diagnosis depending upon the ophthalmoscopic findings and 
the behavior of the visual fields. 

The types of glaucoma above described are classified as primary 
in contradistinction to secondary glaucoma, in which either during 
or as the result of some other ocular disease the intra-ocular tension 
rises above the normal. Secondary glaucoma is sometimes observed 
in the treatment of iritis, where, as a result of the dilatation of the 
pupil, the iris is pushed into the filtration angle, thus interfering 
with the outflow of the ocular fluids. After a severe iridocyclitis, 
with the production of a total annular synechia, or a pupillary 
membrane, the posterior chamber is completely closed from the 
anterior, in this way blocking the natural lymph flow. 

Violence to the eye may result in inflammation to one or more 
of the ocular tissues, and will show the type of inflammation char- 
acteristic to the tissues involved. Traumatism may result in a 
rupture of the ocular tunics, with or without coincident prolapse 
of the contents of the eye. Stab wounds and the penetration of for- 
eign bodies also causing breaks in the ocular tunics; all such injuries 



72 REYNOLDS: EPIDIDYMITIS DUE TO THE COLON BACILLUS 

bring up the question of a retained foreign body, and where the 
history of the accident does not settle this point, efforts should be 
made to locate a foreign body by means of direct, ophthalmoscopic, 
and .T-ray examinations. If located, efforts must be made to remove 
the foreign body. The character of inflammation generally set up 
as a result of penetrating wounds of the globe and retained foreign 
bodies is iridocyclitis. Iridocyclitis of traumatic origin is responsible 
for the majority of cases of sympathetic inflammation in the second 
' eye. ' Patients suffering from an iridocyclitis of the above-men- 
tioned character must therefore be carefully watched for the begin- 
ning signs of sympathetic inflammation, which are photophobia, 
lacrymation, ciliary injection, deposits on the posterior corneal 
surface, posterior synechia, vitreous opacities, and hj'^peremia of 
the retina and optic nerve head. With the development of these 
signs in the uninjured eye removal of tlie injured eye is imperative. 

The subjective sj^mptoms of the inflammatory diseases in the 
anterior ocular segment yield little definite information except 
in glaucoma. 

It is seldom that one of the ocular structures is the seat of dis- 
ease without some involvement in the adjacent tissues. And so 
involved may this participation of two or more tissues in one 
inflammatory process become that even the skilled oculist has 
difficulty in properly differentiating the existing signs. Conjunctival 
injection denotes conjunctivitis, and ciliary injection shows the 
process to be of deeper origin. Ciliary injection occurring in the 
course of conjunctivitis shows an extension of the inflammation 
to the deeper tissues. Conjunctival injection often exists simult- 
aneously with ciliary injection in severe inflammations, but in 
these cases the significant sign is the ciliary’' injection, and it is 
incumbent upon the physician to ascertain the cause for its presence, 
and not regard the case as merely a conjunctival inflammation. 
In iritis the pupil is contracted, whereas in glaucoma it is dilated. 
In conclusion, let me once again warn against the instillation of 
atropine .or other mydriatic into an inflamed eye until the possi- 
bility of glaucoma as a cause of the symptoms is eliminated. 


EPIDIDYMITIS DUE TO THE COLON BACILLUS. 

By Walter S. Eeynolds, M.D., 

CHIEF OF THE CLINIC OF GENITO-URINAIir SURGERY IN THE MEDICAL DEPARTMENT OF COLUMBIA 

UNIVERSITY, NEW YORK. 


The subject of colon bacillus infection of the urinary tract has 
for some time been receiving considerable attention, and as a 
result cases have been reported where this group of organisms 



REYNOLDS: EPIDIDYMITIS DUE TO THE COLON BACILLUS /o 

was found in pure culture accompanying pathological conditions 
in all these structures. It has also been shown that they may be 
frequently found in the urine where no pathological condition is 
present. The ' frequency, therefore, with which these organisms 
may be found present under both normal and abnormal conditions 
leads one to believe that possibly they may be the cause of dis- 
turbances in these organs much more frequently than has been sup- 
posed. Aside from cystitis, where for some time it has been known 
that the inflammation, in the majority of instances, was due to the 
colon bacillus, these organisms did not appear to play an important 
role in diseases of the urinary organs, though there would seem 
to be no reason why other organs should not be equally liable to 
involvement under similar conditions. I have felt satisfied for 
some time that cases of chronic gonorrheal urethritis were pro- 
longed by the presence of these organisms, and while they have not 
seemed to be especially virulent in these cases, it is often difficult 
to get rid of them; but when this is accomplished, I have found 
that the chronic urethritis improved. 

I was lately asked by a friend to examine some slides of secre- 
tion from the genital organs of a woman who complained of a 
discharge which stained her underclothes and who was found to 
have a Bartholinitis. There was a great profusion of colon bacilli, 
but no other organism could be found. Her husband had probably 
not been infected, as he made no complaint. I have at present 
under treatment a young man who one week after intercourse 
noticed a slight discharge from the urethra unaccompanied by any 
marked urinary symptoms, except some slight increase in frequencj^ 
of urination, and where the only organism to be found in the dis- 
charge was a profusion of those resembling colon bacilli. Massage 
of the prostate showed the same organisms in the expressed fluid. 
Naturally the question arising in this case is whether he has acquired 
the infection in intercourse or was the infection derived from his 
own system? 

While it seems reasonably certain that these organisms, though 
perhaps under ordinary circumstances they are not very virulent, 
may quite frequently be the cause of inflammatory conditions of 
the urinary tract, still there are few cases recorded of epididymitis 
as a result of colon bacillus infection, a complication of frequent 
occurrence in other infections, such as gonorrhea and tuberculosis. 

The manner in which infection of the urinary tract is brought 
about is still a matter of discussion, .and it is also unsettled as to 
whether it is necessary that a lesion of the intestinal tract be present 
before the organisms are liberated. In epididj'^mitis occurring with 
some other diseases we see cases where it seems clear that the 
epididymis becomes involved by direct extension through the 
ejaculatory ducts from the posterior urethra or from the prostate. 
Whether it would be possible for infection to take place in this 



74 REYNOLDS: EPIDIDYMITIS DUE TO THE COLON BACILLUS 

way, supposing no inflammatory lesion to be present about the 
opening of these ducts, is questionable, though we find reports of 
cases of epididymitis where colon bacilli were found in the urine, 
but no symptoms of urethritis were present. In such cases the 
possibility of infection taldng place in such manner must, of course, 
be considered. It is to be remembered, however, that a mild 
posterior urethritis or prostitis may give rise to no marked symp- 
toms, and it might be possible in some cases to overlook it unless 
a careful examination was made. 

Dr. George G. Smitlfl reports a case of epididymitis following 
typhoid fever where colon bacilli were found in the urine and 
culture of the fluid from the epididymis after operation showed 
pure culture of typhoid bacilli. Epididymitis following typhoid 
fever is a complication somewhat rarely seen, and the majority 
of works do not mention it at all. There is considerable doubt 
as to whether it is an orchitis or epididymitis. Both Osier and 
Pepper speak of it as an orchitis, and Osier says, it occurs with 
a mild catarrhal urethritis. In Sajous’ Annual there is no mention 
of orchitis or epididymitis in the article on typhoid fever. It does, 
however, state that “Pus is not infrequently found in the urine 
of typhoid patients,” and says, “It may arise from cystitis or 
pyelitis. ” In the same article, under pathological anatomy, we find : 
“ Catarrh of the bladder is sometimes met with, and may be brought 
about by the careless use of the catheter for retention.” So it 
would seem that uncertainty exists not only as to whether it is an 
epididymitis or an orchitis, but as to the effect of the typhoid 
bacilli on the urinary tract as well. It is unfortunate that so many 
loose statements are made in medical works that it is often difficult 
to get at the real facts. In Smith’s case the operation showed that 
it was the epididymis which was affected, and the testicle was 
only slightly if at all involved. 

The condition of the intestinal tract in these cases might, with 
little doubt, afford an open gateway for the escape of the organisms 
into the circulation, and unless it can be shown that a posterior 
urethritis is present it would seem more reasonable to suppose 
that infection takes place in that way notwithstanding the fact 
that the organisms may be found in the urine, rather than to 
believe that they pass into the epididymis through the openings 
of the ejaculatory ducts. Generally spealdng, an epididymitis 
seems to be preceded by a posterior urethritis or prostitis, while 
orchitis results from blood infection. 

In inflammation of the testicle following mumps the infection 
is undoubtedly carried by the blood stream. Nothing is known 
as to the nature of the infection, as these cases seldom come to 
autopsy, and are never operated upon. In like manner in syphilis 
the testicle is the part first involved. 


■ Trans. Amer. Ilrolog, Assoc., 1912. 



REYNOLDS: EPIDIDYMITIS DUE TO THE COLON BACILLUS 75 

It is of interest to observe that since operations for gonorrheal 
epididymitis have become more frequent, cultivation of the fluid 
obtained from the inflamed part, while frequently showing the 
gonococcus on cultivation, in some instances no organisms can 
be found. It is assumed, however, that the gonococcus is the 
cause of the inflammation, since it follows a gonorrheal urethritis. 
Hagner in several articles on the subject has an interesting series 
of cases showing the results of such examinations after operations. 

In tuberculosis it is the epididymis which nearly always is 
involved before the testicle becomes affected. But in tuberculosis 
it is believed by many that the epididymis is always a secondary 
involvement to tuberculosis elsewhere, and is frequently dependent 
on tuberculosis of some of the urinary organs. 

Case. — J. D. I., an unmarried man, aged thirty-seven years, 
was referred to me on May 7, 1912. The previous day he had 
begun to have frequency of urination accompanied by much pain 
and tenesmus. The only cause which could be assigned for the 
trouble was that he had partaken freely of asparagus for dinner 
the night before, and had also had a cocktail or two. He never 
had urethritis, but had been treated for catarrhal prostatitis some 
two years before, which had been relieved by massage and instilla- 
tions of silver nitrate, otherwise he had been perfectly well. 

Examination showed no inflammatory condition of the meatus 
or urethra, and no discharge was present. Urine passed in two 
glasses was equally cloudy — in both the cloudiness was due to pus. 
The urine was not high colored, as he had begun to drink water 
freely as soon as the frequency of urination had commenced. 
Examination of the prostate did not reveal any marked prostatic 
trouble. His tongue was heavily eoated, but there was no apparent 
intestinal disturbance. A diagnosis of cystitis was made, and he 
was ordered aetive catharsis, hot rectal irrigations, suppositories 
of morphine at night, and an alkaline diuretic. After a few days 
of this treatment the pain^ tenesmus, and frequency of urination 
had so much subsided that he was given bladder irrigations of 
a solution of borie acid. 

A specimen of urine obtained from the bladder after washing 
with the boric acid solution was examined by Dr. Peter Irving, 
and showed “many pus cells, epithelium in fair amount, whieh 
looks like that from the kidney pelvis, and organisms, probably 
colon bacilli. ” A culture was made by Dr. D. S. Jessup, whieh 
proved them to be unquestionably colon bacilli. On this finding he 
was requested to prepare a vaccine which could be used if necessary. 
Dr. Irving reported the urine to contain no indican or indol-acetic 
acid, although a pure eulture of colon bacilli Avas present. 

On the tenth day after I first saAv him he began to haA^e some 
pain and tenderness in the left cord and epididymis, AA'ith some 
return of the urinary symptoms. Cold lead and opium solution 



76 REYNOLDS: EPIDIDYJIITIS DUE TO THE COLON BACILLUS 

with an ice-bag and support for the testicle did not prevent 
the epididymis from becoming much enlarged and tender. He 
had been running an irregular temperature from the time his 
cystitis began. It varied from 99° to 101°, and was not markedly 
changed by the development of the epididymitis. The tempera- 
ture did not return to normal until June 6, a period of about one 
month. 

The first blood count by Dr. Irving, on May 11, was as follows: 
White blood cells, 8000; differential polynuclears, 76.2 per cent.; 
lymphoeytes, 20.4 per cent.; eosinophiles, 3.2 per cent.; basophiles, 
0.1 per cent. 

During the first week of the epididymitis he was much more 
uncomfortable from the acuteness of the inflammation than 
patients ordinarily are with a gonorrhoeal epididymitis. For a short 
time hot applications were used in place of the cold lead and opium, 
but were discontinued, as they did not control the pain as well as the 
ice. On May 23, he had a severe chill, lasting for some time, but 
not followed bj'’ any marked rise of temperature. Pain in the 
epididj-mis was severe if the ice was diseontinued. Dr. Charles H. 
Peck was asked to see him, but could find nothing in the kidney 
or epididymis which would seem to call for operative interference. 
At this time the blood examined by Dr. Irving showed: White 
blood cells, 22,000; polynuclears, 87 per cent. There was no sign 
of anj’’ change taking place in the epididymis; it was large and 
tender, but there were no signs of suppuration. It was decided 
to use the vaccines which Dr. Jessup had prepared, and 5,000,000 
were given in the afternoon of May 24. This was followed shortly 
by a chill and rise of temperature to 102.8°. Next morning there 
Avas another chill, and the temperature rose to 103°. Six days 
later another injection of 5,000,000 was given, and this time .was 
followed by no reaction. Again on June 5, 10,000,000 w^ere given 
without causing any disturbance. Later 30,000,000 Avere given, 
and only caused a slight reaction. 

The exudation into the epidid;yTnis Avas extremely s1oa\^ in being 
absorbed, and it AA'as a considerable time before it returned to 
normal. Soon massage of the prostate and irrigations AA’^ere begun. 
The colon baciUi could be found in the fluid obtained after massage 
for some time afterAA^ard, although the urine A\^as perfectly clear, 
and they seemingly caused no disturbance by their presenee. 

In this case the -epididymitis AA'as due to the colon bacilli, AA'hich 
AA'ere found in pure culture in the urine obtained by catheter, and 
also found in the fluid from the prostate. The examination by 
Dr. IrAung points to a pyelitis as AA'ell as the eystitis, AA'hich he 
quite eA'identl}' had. In his case there was no question as to the 
A'irulency of the inflammation in the epididymis, as I haA'e neA^er 
seen a gonorrheal epididymitis AA'hich Avas any more severe, and 
seldom one AA'hich AA'as so prolonged as Avas this one. The use of 



ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 77 

the vaccines did not seem to me to be of any special benefit. Pos- 
sibly if they had been used at an earlier stage the benefit might 
have been more marked. As an autogenous vaccine was used 
there could have been no question as to the proper strain. 

The persistence of the infection is to be noticed in this case. 
As the organisms were found in the urine which had not been 
allowed to remain in the bladder, it would seem a reasonable 
assumption that they were passing downward from the kidney, 
and that for some reason, possibly due to the asparagus, they 
had given rise to the cystitis, with subsequent involvement of the 
prostate, as shown by the conditions of the gland on examina- 
tion and the presence of pus and colon bacilli in the massaged 
fluid. As a result of the prostatitis and posterior urethritis the 
inflammation extended by continuity and epididymitis resulted. 
As I review the case it seems fair to conclude that there had not 
been a sudden invasion of the bacilli, but that in all probability 
they had been present for some time in the urine without causing 
any disturbance; but when suitable conditions were present, they 
were able to set up an inflammation which extended to the 
structures involved. 


THE RATIONAL TREATMENT OF TETANUS, WITH A REPORT 

OF TWENTY-THREE CASES FROM THE EPISCOPAL 
HOSPITAL, PHILADELPHIA.^ 

By Astley Paston Cooper Ashhurst, M.D., 

INSTRUCTOR IN SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; ASSOCIATE SURGEON 
TO THE EPISCOPAL HOSPITAL, ETC., 

AND 

Rutherford Lewis John, M.D., 

BESIDENT PHl'SICIAN, EPIBCOPAL HOSPITAL. 

(Concluded from page 819, June, 1913.) 

TREATMENT OF TETANUS. 

A. The first logical step in the treatment of this disease is the 
removal of the source lohicli supplies the toxin — that is, of the tetanus 
bacilli. If the point of inoculation is known, it should be attacked 
directly. The wound should be opened widely, and should be 
mechanically cleansed of foreign bodies and sloughs. Then it 
should be swabbed out with a 3 per cent, alcoholic solution of 
iodine, rinsed with_ hydrogen peroxide, and filled loosely Avith 
gauze soaked in the iodine solution. ^Ve believe all caustics should 
be avoided, as favoring the growth of tetanus bacilli by the forma- 
tion of sloughs. If the nature of the case demands it for other 

® Read at a meeting of the Episcopal Hospital Clinical Society, November 18, 1012. 



78 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

reasons, amputation should be done; then the stump should be 
left open, and treated as the original wound. Probably in many 
cases it Avill be well to follow Porter and Richardson’s suggestion 
to excise, the related lymph nodes, particularly if they are palpably 
enlarged. 

B. The next indication is to' head off and neutralize the toxin 
already formed. This involves a discussion of the Therapeutic 
Use of Antitoxin (see this Journal for June, 1913, footnote on 
p. 814). 

Before the introduction of antitoxin as a therapeutic measure 
the mortality was from 80 to 90 per cent. (Rose, 1897). Collective 
statistics of cases treated with antitoxin (1897 to 1903), according 
to Sawamura, showed a death rate of from 28 to 45 per cent. Of 
course, a collection of isolated case reports is apt to give too low 
a mortality, owing to the fact that surgeons who have had suc- 
cessful cases will report them, while the larger number do not 
report their unsuccessful cases. But the fact that no better results 
were reported from the therapeutic use of antitoxin in tetanus, 
in view of the remarkable successes from the use of diphtheria 
antitoxin, was explained on the theory that the antitoxin had not 
been used early enough. In 1902, Ullrich, according to Sawamura, 
remedied this apparent defect by collecting 13 cases in which anti- 
toxin had been used early; but only one of these patients recovered; 
and of 54 collected cases, in which it was used early (subcuta- 
neously), between 1899 and 1905, Busch (Sawamura) found the 
mortality was 66.5 per cent. In the elaborate statistics collected 
by Jacobson and Pease the mortality in 191 cases in which anti- 
toxin was used, was 69.6 per cent.; these statistics are especially 
valuable because they represent series of consecutive cases from 
various sources. Pricker has published statistics of 40 consecutive 
cases: in the first IS (1889 to 1897), no antitoxin was used, and 
16 deaths occurred (88.8 per cent.); in the last 22 cases (1897 to 
1902), antitoxin was used, and the mortality was only 55.5 per cent. 
In spite of this decrease in mortality, many physicians have denied 
that antitoxin has any therapeutic value in acute severe cases. 

Huber has reported recently in great detail 69 cases of tetanus 
treated in Sauerbruch’s clinic at Zurich, between 1881 and 1911. 
Of this whole number, 18 patients recovered and 51 died, a mor- 
tality of 74 per cent. Before 1900 antitoxin was not used, and of 
31 patients treated without it, 20 died, a mortality of 64.5 per cent. 
Antitoxin was used in all of the 38 patients treated since 1900, 
but of these only 7 recovered, while 31 died, a mortality of 81.5 
per cent. Huber thinks all of these 7 patients would have recovered 
even if no antitoxin had been given. But the total amounts used 
were small (the greatest, amount used in any one ease was 150 c.c. 
= 375 — 750 A. E.), and the mode of administration is open to 
criticism; this will be discussed later (p. 86). 



ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 79 

But here, again, as in the question of its prophylactic use, we 
must inquire as to the frequency, the quantity, and the site of 
the injections. In most of the isolated case reports the antitoxin 
has been injected only once or twice, in small quantities, and 
subcutaneously. 

Exactly how the antitoxin acts upon the toxin is not known. 
According to Solieri, the idea that its neutralizing action is a direct 
chemical one, as that of an acid on an alkali, has been abandoned. 
Donitz taught that it could not only neutralize the toxin circulating 
in the blood, but also could loosen toxin already bound in the 
central nervous system and drive it out of its almost impregnable 
fortress. According to Metschnikoff, tetanus antitoxin stimulates 
phagocytosis. From numerous experiments Kraus and Amiradzibi 
conclude that antitoxin cures by drawing the toxin out of the 
cells where it is lodged, but does not itself enter into the toxin- 
containing cells. Recovery under the use of antitoxin they think 
depends on the possibility of this diffusion; and as such diffusion 
can take place experimentally through a membrane of collodion 
and through reeds (Schilfrohren), they think it is not necessary 
in the human body for antitoxin to be in direct contact with toxin 
for it to exert its neutralizing influence on the latter. 

I. Site of Injection of Antitoxin. The following sites of 
injection have been advocated: Subcutaneous, intravenous, intra- 
spinal, intraneural, intracerebral, and intramuscular. 

1. Subcutaneous Injections. This is the method usually em- 
ployed, but, as already noted, the reports are not encouraging. 
If administered in this way, the antitoxin is absorbed by the 
lymphatics, transported to the veins, passes through the lungs, 
and finally, is distributed through the arterial system to all parts 
of the body. Only a homeopathic dose ultimately reaches the 
motor nerves through which the toxin is being carried to the spinal 
cord, while by far the greater part of the antitoxin is distributed 
to the viscera, where it can be of no possible use. Administered 
in this way, overwhelming amounts are required to produce any 
effect, and it is evidently the height of extravagance so to 
employ it. 

The manufacturers of antitoxin recommend the administration 
of from 15,000 to 18,000 units (subcutaneously) every three hours; 
and such an amount (120,000 to 144,000 units) in the course of 
twenty-four hours is not unreasonable when it is recollected that 
only a very small fraction of what is administered subcutaneously 
can be expected to reach the seat of disease, while the rest is a 
shocking waste of a valuable and very costly remedy. For the 
amount mentioned (144,000 units) the cost is about $100, even 
with the discount allowed to hospitals. (One dozen tubes of 1500 
units each (18,000 units) cost the Episcopal Hospital, $12.07; 
eight doses of 18,000 units cost $101.56). Note the history of 



80 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

Case 23, of our series; here antitoxin was administered subcuta- 
neously in appropriate doses (99,000 units on the first day; 65,000 
units on the second day; 60,000 units on the third day) — to a total 
amount of 224,000 units,^” and recovery followed. The cost to the 
Hospital, with discounts deducted, was about $180. The patient 
was a very poor man, a charity case; but when told of the expense 
of his treatment, he and his friends collected $10 and donated that 
sum to the hospital, as a “Widow’s Mite.” 

Compare with this history the case of a severer case of tetanus 
(Case 11 of our series): On the first day 3000 units were admin- 
istered intraspinally; on the second day, 750 units were injected 
into the sciatic nerve, and 750 units deeply into the tissues around 
the wound. The patient recovered, and the total cost to the 
hospital was about $3. 

The quantities of antitoxin used in each case were logically 
correct, but only in Case 11 was the mode of administration 
rational. 

2. Intravenous Injections. The effects of intravenous injections 
of antitoxin have been studied experimentally by v. Graff, both 
as regards prophylactic and therapeutic use; 

(а) In a first series of experiments he administered the tojdn 
by intramuscular injection, (a) Antitoxin was administered to 
14 rabbits before toxin was injected; of these animals only 4 died, 
and not one had positive signs of tetanus, (h) Antitoxin (intra- 
venously) and toxin (intramuscularly) were administered simul- 
taneously to 8 rabbits; 4 of these died, but only 1 presented symp- 
toms of tetanus, (c) Toxin Avas administered intramuscularly 
to 8 rabbits, and from fifteen to eighteen hours later antitoxin was 
injected intravenously; 4 of these rabbits died, 2 with only local 
tetanus, and 2 with general tetanus. 

(б) In a second series of experiments he administered the toxin 
by intraneural injection, (a) Toxin was injected intraneurally 
in 6 rabbits; all died of tetanus in from thirty-six hours to five 
days. (5) Antitoxin Avas administered intraA'^enously to 19 rabbits 
from six to ten hours before a lethal dose of toxin Avas injected intra- 
neurally. Only 2 of the animals liA’-ed and 17 died after intervals 
of from five to twenty-five days; but in the fatal cases death was 
attributed to intercurrent gastro-enteritis, no evidence of tetanus 
having been present, (c) Antitoxin was injected intravenously 
twenty-four hours before toxin was injected intraneurally; of 5 
rabbits so treated none developed tetanus, 2 lived, and 3 died from 


'0 The nearest approach to this total quantity that we can find reported was administered 
to a patient under the care of Beates and Thomas. The most given on any one day was 97,940 
units, the total amount being 213,700 units; but as the patient was a boy of fourteen years 
(weight 130 pounds), this amount may be relatively greater. Neary administered 280,000 
units to his patient, who recovered; but as this quantity was spread out over a period of two 
weeks (10,000 units every twelve hours), it is not comparable to the doses above mentioned. 



ASHHUKST, JOHN: THE RATIONAL TREATMENT OP TETANUS 81 

no apparent cause in from four to nine days, (d) Antitoxin (intra- 
venously) and toxin (intraneurally) were injected simultaneously; 
of 5 rabbits so treated none developed symptoms of tetanus, yet 
all but 1 died in less than eight days, (e) Toxin was injected intra- 
neurally, and from fourteen to eighteen hours later antitoxin was 
injected intravenously; of 3 rabbits so treated, the first developed 
local tetanus, but recovered, only to die on the ninth day of puru- 
lent peritonitis; the second developed local tetanus but recovered; 
the third developed local tetanus and then general tetanus, and 
died on the fifth day of general tetanus in spite of intravenous 
injections of antitoxin repeated every day. (/) Toxin was injected 
intraneurally, and from fifteen to seventeen hours later antitoxin 
was administered intravenously; of 7 rabbits so treated, 4 died 
as if no antitoxin had been given; in 1 life was prolonged by the 
treatment until the sixth day, when death from general tetanus 
occurred; and in 2 recovery ensued, although very severe general 
tetanus had already developed. These 2 recoveries, v. Graff thinks, 
are to be explained only on the ground that the antitoxin was able 
to neutralize toxin already absorbed by the nervous system. 

The conclusion of v. Graff is that intravenous administration 
is the most effective method, but that subdural (intraspinal) 
administration holds next rank, because he believes in this way 
antitoxin is rapidly discharged from the cerebrospinal fluid into 
the blood. “ Intraneural injections of antitoxin were not employed 
by V. Graff, but the results of Sawamura’s experiments, detailed 
below (p. 84), as to the relative therapeutic value of intravenous 
and intraneural administration of antitoxin, seem to demonstrate 
conclusively the superiority of the intraneural method. From these 
experiments, to be discussed presently, it is evident that antitoxin 
administered only by the intravenous method is not very effective; 
and the same objections as to extravagance apply to this as to the 
subeutaneous method, only in less degree, because the antitoxin 
reaches the circulating toxin in shorter time, and can exert its 
influence sooner on the toxin already absorbed by the peripheral 
nerves or the spinal cord, if only it is used in sufficient quantities. 

That the amount required to produce any therapeutic effect 
is immense, is proved by the observations of v. Leyden; he neu- 
tralized all the toxin in the patient’s circulating blood, rendering 
it harmless to experimental animals; but his patient died of tetanus. 
And in a patient under the care of Blumenthal and v. Leyden, 
they succeeded in neutralizing almost entirely the circulating 
toxin, but much toxin remained in the cerebrospinal fluid. More 
recent observations tend to show that the amount of toxin circu- 
lating in the bipod rapidly diminishes after the first few days of 
the disease, while that in the nervous tissues steadily increases. 

'' ^ * Graft says that Xj. Simon has treated 0 consecutive cases of tetanus by intravenous injec- 
tions of antitoxin, with 4 recoveries. 



82 ASHHURST, JOHN : THE RATIONAL TREATMENT OP TETANUS 

The following advantages of intravenous administration are 
pointed out by v. Graft’ : 

(i) The antitoxin gets into the blood as soon as possible. 

(ii) This method can be used even when the point of inocula- 
tion is doubtful, or unknown, or inaccessible. He recommends it 
especially for cases of puerperal origin. 

(iii) It is easier than intraspinal or intraneural injection, is less 
painful, and can be repeated. 

As regards the first advantage, it may be replied that it is more 
important to have the antitoxin in the nerves and spinal cord than 
in the blood. Intravenous administration is not the only available 
method for cases mentioned in the second paragraph, since intra- 
spinal (subdural) injections may be made; and these, as well as 
intraneural injections can be repeated as often as is desirable. 
However, they are more painful to the patient, sometimes requir- 
ing a general anesthetic, and intraneural injections require more 
accurate anatomical knowledge and surgical skill. 

3. Intraspinal {Subdural) Injections. These were originally sug- 
gested by Jacob; but he came to the conclusion, after some experi- 
mental work, that thej^ were useless,' because he thought all the 
antitoxin so administered rapidly escaped into the general circula- 
tion. Sicard, however (quoted by Hofmann), obtained better 
results in his experiments udth dogs. The method was first used 
successfully in 1899 by v. Leyden, who thought this the best method 
of all, emphasizing the fact that the antitoxin thus came into 
intimate relation with blood- and lymph-vessels of the cord, and 
so was conveyed more quickly to the medullary cells. ' Whether 
or not antitoxin injected into the subdural space of the cord acts 
directly upon the cord itself, or upon the nerve roots, does not 
appear to have been determined. Certainly it has not been dis- 
proved, and if reasoning by analogy with tetanus toxin be allowed, 
it is altogether probable that antitoxin injected intraspinally is 
in large part absorbed into the nerve roots and the cord itself, 
especially if the pia or the nerve tissue is punctured. Mere with- 
drawal of cerebrospinal fluid by lumbar puncture has been sug- 
gested as a therapeutic measure, and it is possible that the rapid 
decrease in severity of the symptoms often seen may be produced 
in this way. It is not reasonable to expect the specific action of 
the antitoxin to be manifested for several hours. 

Though, experimentally, treatment of tetanus by intraspinal 
injections of antitoxin has not been very encouraging, much more 
satisfactory results have been obtained in actual practice. 

Hofmann reported from v. Hacker’s clinic, at Graz, a series of 
30 consecutive cases of tetanus. From theoretical considerations 
the 3 ^ were opposed to the intraspinal administration of antitoxin, 
and in the first 13 cases only subcutaneous injections were used; 
of these patients 7 died, a mortality of 53.8 per cent. In 3 of these 



ASHHURSTj JOPIN: TIPE RATIONAL TREATMENT OF TETANUS S3 

cases, 2 of them fatal, carbolic acid was also employed subcuta- 
neously. In a fourteenth case, which also died, both subcutaneous 
and intraneural injections were given. Of the cases treated by 
subcutaneous injections only, 5 came under treatment within 
thirty hours of the onset of symptoms; and of these patients (mostly 
acute cases), 4 died, a mortality of 80 per cent.; 8 cases came under 
treatment more than thirty hours after the onset of symptoms, 
and of these only 3 patients died, a mortality of 37.5 per cent. 
When the fifteenth patient came under treatment, intraspinal 
injections of antitoxin were tried, because other treatment did 
not control the disease, which ivas of the acute type, and very 
severe. This patient recovered. Then in the succeeding 15 patients 
antitoxin was always given intraspinally ; and of the entire series 
of 16 xxiiicnts treated^ by antitoxin subdurally, only 2 died, a mortality 
of 12.5 per cent. ; 4 of these were very acute cases, yet all recovered. 
In 2 cases of this latter series antitoxin was injected intraneurally 
as well as intraspinally. 

Rogers, in a series of 7 acute cases, employed intraspinal as 
well as intraneural injections, and in administering the intraspinal 
injections he endeavored to inject at least some of the antitoxin 
directly into the spinal cord (intramedullary injection), so that 
it might reach the nerve centres as quickly as possible. Of his 
7 patients, only 3 died. Of 5 patients under the care of Luckett, 
all the 4 who were treated by intraspinal injections recovered, 
while the fifth patient, not so treated, died. 

In our own series of cases intrapsinal injections of ’antitoxin 
were employed only in 7 patients, of whom 4 died, a mortality of 
57 per cent. ; but in 1 fatal case the injeetion was made only three 
hours before death, as a last resort (Case 2); in another, death 
was eaused by a subsequent overdose of magnesium sulphate, 
injeeted into the subdural space (Case 19) ; and the 2 other deaths 
occurred in extremely acute cases (Cases 12, 13). In all the suc- 
cessful cases improvement was rapid (Cases 8, 10, 11). 

4. Intraneural Injections. This method was first employed 
clinically by Kiister in 1902. Jacobson and Pease suggested that 
the pressure, rather than the specific action of the antitoxin, bloeked 
further absorption of the toxins; but an e.xperiment in which 
Sawamura employed salt solution instead of antitoxin for. intra- 
neural injection, seems to disprove this supposition. 

As it is a well ascertained fact that most, possibly all, of the 
toxin reaches the spinal cord only by travelling up its nerves, it is 
theoretically logical to inject the antitoxin into the nerves, in order 
that, like the toxin, it may reach the spinal cord and rout the 
enemy by the easiest road. That it will do this, when injected 
intraneurally, admits of no doubt in view of the overwhelming 
experimental evidence on the point. Just how the antitoxin acts, 
and by which intraneural route (axis eylinders or endo- and peri- 



84 ASHHURST, JOHN: THE RATIONAL TREATJIENT OF TETANUS 

neurium) it reaches the cord, has not been determined. Now, 
though most of the toxin ascends the nerves leading from the 
wounded part, other lesser amounts of the toxin are simultaneously 
invading the cord through all the motor nerves of the body; and 
it is manifestly impracticable to expose and inject antitoxin into 
all of these nerves. Moreover, when the site of inoculation is 
doubtful, or unknown, uncertainty must exist as to which nerves 
should have injections of antitoxin. The only methods we possess 
for reaching all the nerves at once are (1) intravenous injections, 
and (2) intraspinal injections. In no case, therefore, should the 
surgeon depend upon intraneural injections alone, and in no case 
should he omit either intraspinal injections or injections into the 
motor nerves leading from the site of inoculation. Especially if 
the point of inoculation is in a muscular part, or in the upper 
extremity, Avill the main bulk of the toxin reach the cord by the 
motor nerves of the inoculated part; and in such cases particularly 
are intraneural injections requisite. 

Sawamura conducted experiments to determine the relative 
therapeutic value of antitoxin administered intravenously and 
iniraneurally . (1) In a first series of 4 rabbits he administered 

antitoxin intravenously from eighteen to nineteen hours after toxin 
had been injected intramuscularly; all 4 rabbits died of tetanus. 
(2) In a second series of 6 rabbits he administered antitoxin either 
iniraneurally alo7ie or iniraneurally as well as intravenously, from 
eighteen to hventy-four hours after toxin had been injected intra- 
muscularly; and although the total annount of antitoxin was no 
greater or even less than that which had been employed in his 
first series, yet only 2 of the rabbits died, and these deaths did 
not occur until the twelfth and the sixteenth days, in cases where 
the total amount of antitoxin Avas small, where it had been injected 
late, and Avhere it had been given only intraneurally, and not 
intravenously as well. (3) In a third series of 3 rabbits he admin- 
istered antitoxin intravenously forty hours after the intramuscular 
injection of toxin, and seventeen hours after the appearance of 
the first symptoms of tetanus; he administered antitoxin in large 
amounts intravenously, intrammcularly , or s7ihcutaneously, or hy all 
three methods, and on several subsequent days; yet all these rabbits 
died of tetanus in from nine to fourteen days. (4) In a fourth series 
of 4 rabbits he administered a much less amount of antitoxin intra- 
neurally, after the same interval since the intramuscular injection 
of the toxin as in the third series; yet not 1 of these 4 rabbits died. 
In another rabbit, similarly prepared, for the sake of a control 
experiment, he injected salt solution into the nerve instead of 
antitoxin; but this rabbit died of tetanus on the ninth day. 

SaAvamura says (p. 85): “To increase the value of intraneural 
injections of antitoxin, one must strive not only to neutralize the 
toxin in the peripheral nerves or that Avhich is later to reach them, 



ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 85 

but also to bring the action of the antitoxin to bear on the toxin 
already in the spinal cord; and, therefore, the injection should 
be made into the nerve as near the cord as possible; and centrally 
from this point as large an amount of antitoxin as is possible must 
be injected.” He thinks that if in his earlier experiments (the second 
series quoted above) he had injected the antitoxin into the central 
instead of into the peripheral part of the nerves, he would have 
had still better results. 

There are few clinical reports of cases treated by intraneural 
injections of antitoxin; most of them are isolated cases, and hence 
are of little value. Kiister’s patient, the first so treated, recovered. 
Rogers has employed this plan in 7 cases, with 4 recoveries and 
3 deaths, a mortality of 43 per cent. (In all these cases intraspinal 
injections were employed also.) Sawamura, in 1909, collected 
12 isolated cases of tetanus, treated by intraneural injections of 
antitoxin, with only 4 deaths, a mortality of 33 per cent. In our 
own series of cases it was employed only twice (Cases 11 and 13), 
only the first patient recovering. 

In the patients who have recovered after this treatment, no 
disability appears to have been caused except in Kiister’s case, 
where some neuritis and muscular atrophy and contractures 
occurred; and these may have been due to the effects of the original 
injury and not attributable to the treatment employed. Our 
own patient suffered no inconvenience from the injection made 
into his sciatic nerve. 

5. Intracerebral Injections. These were originated by Roux and 
Borrel, who found the method valuable in experimental work: 
of 45 guinea-pigs thus treated, 35 recovered; whereas of 17 treated 
by subcutaneous injections of antitoxin only 2 recovered. But 
when applied to mankind, the results have been absolutely bad — 
not only has the mortality not been reduced, but lasting cerebral 
lesions have been produced in some of the patients who recovered. 
In 88 cases collected by v. Graff, in which intracerebral injections 
were used, there were 71 deaths, a mortality of over 80 per cent. 
Sawamura quotes the follomng statistics for intracerebral injee- 
tions: Lambert, 52 cases, 63.43 per cent, mortality; Lereboullet, 
26 cases, 67.5 per cent, mortality; Steuer, 55 cases, 67.3 per cent, 
mortality. 

6. Intramuscular injections have not been employed in any large 
series of cases. Antitoxin injected around the wound, whether 
as a prophylactic or as a therapeutic agent, should be given into 
the muscular tissues whenever possible, to afford it a readier access 
to the motor nerves. As a therapeutic method intramuscular 
injection is better than the subcutaneous, but is perhaps inferior 
to the intravenous, and certainly is inferior to the intraspinal 
and intraneural methods. 



86 ASHHURST, JOHN: THE RATIONAL TREATMENT OP TETANUS 

II. Frequency of Injection of Antitoxin. The series of 
cases reported by Huber has already been referred to. He thinks 
the antitoxin employed was of no value, and when we come to 
study his case reports it is quite evident that in most cases this is 
true. But it is true because antitoxin was not given often enough 
to be of any service, as well as because the total quantities were 
absurdly small, in view of the fact that most of it was injected 
subcutaneously. In 17 cases one injection alone was given, and 
1 patient recovered. In 16 cases two injections were given, and 
4 patients recovered. In 2 cases three injections were given, and 
none recovered. In 3 cases four injections were given, and 2 
patients recovered. Nor is it true that multiple injections were 
not given because the patients did not survive long enough. Even 
a patient who dies in twenty-four hours after coming under treat- 
ment lives long enough to receive at least eight subcutaneous 
injections. When it is administered intravenously larger amounts 
can be given at one tihae, and one or at the most two injections 
in twenty-four hours should suffice. Intraspinal injections seldom 
are requisite more than once daily, and often only every third 
day. Intraneural injections can be repeated daily if required; 
this was done on three consecutive days in Case 13 of our series, 
but unfortunately without a successful result. 

HI. Quantity of Antitoxin Injected. No matter what the 
method of injection, the most iviportant thing is to get the maximum 
quantity of antitoxin indicated into the patient's body as soon as 
possible. Delay even of a few hours may determine a fatal result; 
25,000 units given within the first three hours almost certainly 
are of more use than 50,000 units given after six hours, or given 
in divided doses. If one determines to use antitoxin at all, he 
should, we believe, make it a rule to administer it as early as pos- 
sible, and to administer the total quantity indicated as nearly as 
may be all at one time. There can be scarcely any doubt that in 
most of the reported cases, as for example, in Huber’s series, the 
amount of antitoxin administered has been utterly inadequate. 

As already pointed out, if the injections are given subcutaneously, 
immense quantities are indicated. For an adult, with the usual 
acute type of case, at least 100,000 units are required in the first 
twenty-four hours; though a less amount may be sufficient for a 
child or for a comparatively mild case, one cannot be sure of the 
fact, and it is better to give too much than not enough. Admin- 
istered intravenously, a less amount is sufficient; how much it is 
difficult to sajL Probably 15,000 to 25,000 units should be adinin- 
istered at first, and if no effect is apparent, or if the good effect 
wears off, a similar amount should be given after the lapse of 
eighteen to twenty-four hours. If given intraspinally , from 3000 
to 10,000 units should be given, according to the severity^ of the 
case; this need not, as a rule, lie repeated in less than eighteen 



ASUHURST; JOHN I THE RATIONAL TREATMENT OF TETANUS 87 

to twenty-four hours. Even when administered intraspinally a 
certain interval must elapse before the effect of the antitoxin can 
be apparent. Intranmral injections should be made in as great 
amounts as the nerves will absorb. We have injected 1500 units 
into the sciatic nerve, all at once, on several occasions, and 750 
units into each of the anterior crural and obturator nerves. If 
the injections are slowly made practically all of this quantity can 
be introduced among the nerve fibers. 

Carbolic Acid Injections in the Treatment of Tetanus. 
This method was first brought to the attention of the profession 
in 1893 by Bacelli, who had employed it since 1888. The well- 
known anesthetic properties of phenol indicate that it has an 
affinity for nervous tissue, and it had been used successfully by 
Bacelli and others in cases of neuritis before he adopted it in cases 
of tetanus. According to Imperiali, carbolic acid is both anti- 
bacterial and antitoxic to the Bacillus tetani, and acts, moreover, 
as a nervous sedative. He has collected 190 cases treated by 
Bacelli’s method, with 157 recoveries and 33 deaths, a mortality 
of only 17.3 per cent. He classified the cases thus: 


Mortality. 

Severe cases, 94, with 2 deaths and 92 recoveries 2.1 per cent. 

Severest oases, 39, with 17 deaths and 22 recoveries 43.5 per cent. 

Fulminating oases, 15, with 14 deaths and 1 recovery 93.3 per cent. 


These statistics are open to the usual objections applicable to 
collected cases; and it is strange that among so large a number 
of case reports no cases appear which may be classed as mild or 
chronic in type. It may be that the Italians, recognizing that 
everything is comparative, class as severe those cases which we 
consider mild, on the theory that even a mild attack of tetanus 
is a severe disease. Imperiali, however, quotes Meoni as having 
observed 6 cases of tetanus in the past four years, all treated by 
carbolic injections, and with only one death. Surgeons in other 
countries, however, have not reported as successful results. Pearce 
Kintzing, almost alone in this country, reports favorable results; 
he treated 7 patients by carbolic injections, and all recovered; in 
3 of these cases the onset of the disease was acute, in 3 the onset 
is not described, and in 1 the onset was very gradual. In less 
than half of his cases could the disease be considered very severe 
in type. 

Bacelli’s plan is to administer 1 c.c. of a 1 per cent, solution 
every few hours, preferably into the muscles along the spine, until 
SO or 100 centigrams are given in twenty-four hours.i" In none 
of the cases mentioned by Imperiali did the total amount admin- 

I 

Most preparations of antitoxin in this countiy^ have added, as prescn-ative. 0.5 per cent, 
of trikresol (Hitchens). Some of the foreign sera are said to contain 0.5 per cent, of phenol. 
Any therapeutic effect this may have must be beneficial in cases of tetanus. 



88 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

istered in twenty-four hours exceed 50 centigrams. Kintzing 
made a 10 per eent. solution by dissolving the deliquesced crystals 
of phenol in sterile water; the full adult dose was 10 drops of this 
10 per cent, solution (equivalent to 1 grain of pure phenol), which 
was diluted in 30 or 40 minims of sterile water, just before being 
injected. Most physicians have preferred to use a weaker solu- 
tion (0.5 per cent.), and to make the injeetion every one or two 
hours, carefully watching for constitutional symptoms of carbolic 
acid poisoning. The tolerance of tetanus patients for carbolic acid 
is amazing. 

Phenol injections were employed in only one patient in our 
series (Case 20), in conjunction with small amounts of antitoxin 
subcutaneously. It was a mild, chronic type of case, of puerperal 
origin, and though the patient survived the disappearance of all 
tetanic symptoms for a period of nine days, she eventually died 
from puerperal sepsis. 

Camus has made a series of experiments to determine the com- 
parative value of carbolic acid, magnesium sulphate, and anti- 
toxin in the treatment of tetanus. Dogs were used, and the animals 
in each series received exactly the same amount of the same toxin, 
at the same time. These investigations show that magnesium sul- 
phate (intraspinally) and carbolic acid (subcutaneously) have no 
influence on the evolution of tetanus, no matter in what amounts 
or at what stage of the disease they were administered. Magne- 
sium sulphate has no other action than as a spinal depressant; and 
while carbolic acid possibly may have some antibacterial action, 
it has no effect on the flxed toxin nor on the toxin in course of 
fixation. Antitoxin, alone, injected simultaneously into the cerebro- 
spinal fluid by lumbar puncture, intravenously, and subcutaneously, 
gave very much better results. 

Cholesterin Injections in the TREATiUENT of Tetanus. 
Experiments having shown that it is the cholesterin of the central 
nervous system for which tetanus toxin has special affinity, it 
occurred to Almagia and Mendes that hypodermie injections of 
this substance might neutralize the toxin. In 2 patients they 
used successfully injections of from 15 to 30 centigrams of cholesterin 
in 10 c.c. of distilled water; Pribram, however, reports the use 
of cholesterin in 3 patients, all of whom died. Among other sub- 
stances which have been found experimentally to be capable of 
neutralizing tetanus toxin is urea (Sewaki). 

C. The third indication in the treatment of tetanus is to depress 
the functions of the spinal cord. So far we have considered only 
methods to check the supply of toxin and to neutralize the toxin 
already- formed. Now we come to an equally important factor, 
because even if the supply of toxin can be stopped promptly, 
and even if the toxin not yet firmly bound to the nerve tissues 
can be completely neutralized, there is in almost every case a 



ASHHURST, JOHN; THE RATIONAL TREATMENT OF TETANU.S 89 

large amount of toxin which has become impregnably entrenched 
in the central nervous system,, particularly in the spinal cord, 
and none of the methods of . treatment hitherto discussed has any 
influence over it. Until its action is exhausted it continues to stim- 
ulate the motor, and to a less degree, the sensory tracts of the 
spinal cord, and kills the patient by exhaustion. The only -way 
to remedy this state of affairs, so far as we know, is to depress 
the functions of the spinal cord. We have at our disposal a number 
of drugs whose main therapeutic action is to render the spinal 
cord less susceptible to stimulus. Administration of one or more 
of these remedies forms an integral part of any rational plan for 
the treatment of tetanus. The drugs most often employed are 
chloral, chloretone, and similar products; the bromides; physo- 
stigma, hyoscine, morphine, and magnesium sulphate. 

The usual doses of these drugs, recommended for ordinary 
occasions, do not apply to the treatment of tetanus. The object 
is to give enough of the drug to produce therapeutic action, and 
until this has been obtained the dose may be steadily increased. 
But there is one caution always to be kept in mind: this is, that 
the gastro-intestinal tract of a patient vdth tetanus may not absorb 
as readily as might be expected, and there is danger that drugs 
will accumulate in the bowels and be suddenly absorbed in over- 
whelming doses when a turn for the better occurs. This may 
be theoretical reasoning, but we are sure we have seen more deaths 
from tetanus ivith the patient completely relaxed than in convul- 
sions. In our series of 23 cases (13 deaths) the condition at death 
is noted in all but 4 (Cases 1, 7, 17, 21); only 3 (Cases 4, 16, 18) 
died in spasm or convulsion, and 6 (Cases 2, 5, 12, 13, 19, 22) died 
in complete relaxation; and in some of these cases the condition 
was due to overaction of the spinal depressants employed. 

We believe most reliance can be placed on the use of chloral 
and the bromides. Hutchings employed chloretone in 6 cases with 
only 1 death, and he warmly advocates this drug. It is admin- 
istered by mouth or rectum in doses of from 30 to 60 grains, dis- 
solved in whisky or in hot olive oil. In our series it was employed 
three times: Case 12 died after being comatose for twenty-four 
hours; Case 13 died after being comatose for three hours; Case 20 
died from puerperal sepsis. In both Cases 12 and 13 the adminis- 
tration of chloretone was stopped as soon as the patients began to 
show signs of coma, but without avail. 

Morphme as the only depressant was used in only one case in 
this series (Case 21), the patient dying. We believe it is less effec- 
tive as a spinal depressant than cliloral and the bromides, and that 
it never should be employed to the exclusion of these drugs. In 
combination with other spinal depressants it was systematically 
employed only in Cases 1, 5, 22, and 23, three patients dying. 

Hyoscine was used in Case 15, the patient recovering. 



90 ASIIllURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

Chloral ami bromides were employed in practically all cases 
except Case 21, in which morphine alone was used. 

Magnesium Sulphaie. In 1906, Blake adopted intraspinal 
(subdural) injections of magnesium sulphate in cases of tetanus. 
The treatment is based on the anesthetic effect of intraspinal 
injections of this drug, as determined by Meltzer in 1905. A 25 
per cent, watery solution of the chemically pure drug is employed, 
and 1 c.c. of the solution is used for everj^ twenty-five pounds of 
body weight. In heavy adults, however, this dosage might prove 
excessive, as it might also in some women and young children. 
Fox, in 1910, collected 24 cases which had been treated by intra- 
spinal injections of magnesium sulphate. Among these patients 
there were 11 deaths, a mortality of 45. S per cent. Such isolated 
case reports have little value, as they give no true idea of the 
value of a remedy. Only when some large consecutive series of 
cases has been treated with magnesium sulphate can we determine 
its proper place in the treatment of tetanus. According to Fox’s 
table, J. N. Henry is the physician who has had most experience 
with this method of treatment. He reported 4 cases, with 3 deaths, 
1 of which may have been caused by magnesium-sulphate poison- 
ing. In our own series of cases intraspinal injections of magnesium 
sulphate were employed in 3 instances (Cases 17, 19, 22), and all 
the patients died, 1 (Case 19) undoubtedly of an overdose. Other 
cases have been reported in which death was attributed to the 
remedy rather than the disease (Henry, Hessert), or in which a 
fatal termination was averted solely by resort to active stimula- 
tion and artificial respiration (Soutter). 

Magnesium sulphate has also been used subcutaneously. Miller 
quotes 3 mild cases with recovery, and Paterson reports 1 successful 
case. 

The experiments of Camus, concerning the therapeutic value 
of magnesium sulphate, have already been mentioned. 

D. The 'patient, as well as the disease, must be treated; and we 
come finally to say a few words about feeding, nursing, etc. When 
first seen it is well to administer a purge; when the disease is once 
fully established, it may be very difficult to secure an evacuation 
of the bowels. Eetention of urine must be watched for and relieved 
by the catheter. Isolation is desirable rather for the sake of pro- 
tecting the patient from noise than for the purpose of preventing 
contamination of other patients, which is very rare.^^ Slamming 
doors, loud and especially sudden talldng, and in fact noises of all 
Idnds should be prevented. The patient’s ears may be stopped 
with cotton, and the floor heavily carpeted. A bed that squeaks 


Reynier says that in 1902 his assistant carried spores on his ungloved hands from one hos- 
pital, where he had amputated for tetanus, to another hospital where he infected 3 patients who 
died of tetanus after operations by this assistant. Now that gloves are habitually worn, such 
an occurrence could hardly take place. 



ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 91 

during the convulsions is a great annoyance. Window frames 
should be kept from rattling. Nursing must be constant and 
painstaking. Food must be administered at all hazards, by a 
nasal tube if necessary. Saline solution by the bowel, as in cases 
of peritonitis, tends to overcome the dehydration of the tissues 
produced by excessive muscular activity. Drugs may be admin- 
istered in the rectal infusion, hypodermically, or by mouth. 

Summary. From the foregoing discussion it is evident that 
the rational treatment of tetanus comprises the four indications 
enumerated at p. 812. The care of the wound, both as a prophy- 
lactic and as a curative measure, is most importaiit.^ The neutral- 
ization of the toxin, by the rational use of antitoxin, is indispensable; 
and we think we have demonstrated the inadequacy of the dosage 
usually employed for subcutaneous administration, and the neces- 
sity of intraneural, intraspinal, and probably also of intravenous 
injections. The excellent results reported in some quarters from 
the use of carbolic-acid injections should be remembered; it is a 
remedy much more readily obtainable than antitoxin. The third 
indication, to depress the fimctions of the spinal cord, must not be 
met to the exclusion of the foregoing. Those who are enthusiastic 
in the use of intraspinal injections of magnesium sulphate seem to 
forget that unless they also employ antitoxin in a rational manner 
they are doing nothing to aid the body tissues to withstand the 
onslaught of the disease. Finally, the care of the patient, nursing 
and feeding, is the most practical part of the treatment, and one 
without which all the other parts may fail of their effect. 

When we encounter another case of tetanus, we hope to be 
able to apply rational treatment in the following manner : 

The patient will be placed in quiet, with competent nursing 
facilities. As soon as possible after coming under observation, 
whether this be in the small hours of the night or at bright noon 
tide, the motor nerves leading from the wounded part will be 
exposed, as near to the cord as practicable, and as much antitoxin 
as each Avill contain will be injected toward the spinal cord.^^ An 
intraspinal injection of at least 3000 units will then be made accord- 
ing to the usual technique for spinal anesthesia. If it is possible 
to prick the cord ndth the needle, so much the better. Next the 
wound of entrance of the infection will be widely opened, all foreign 
bodies, sloughs, etc., will be removed by forceps, scissors, or scalpel; 
the wound will be irrigated with hot peroxide of hydrogen, swabbed 


** For wounds of the sole of the foot, it is sufficient to inject the sciatic nerve; for those of other 
parts of the lower extremity, not alone the sciatic hut the anterior crural and obturator ner\'e3 
as well should be injected. For wounds of any part of the upper eztr€7nity, the brachial plexus 
should be exposed above the clavicle, and an injection should be made into each of its cords. 
These operations should be done under general anesthesia, for which we prefer chloroform. A 
strong linen ligature is to be looped loosely around each of the nerves exposed; the ends of these 
ligatures are to be left long, and used to identify the nerves and draw them up into acce.s.sible 
positions for the purpose of subsequent injections of antitoxin should these prove ncces.sarj'. 



92 ASHHUKST, JOHN: THE RATIONAL TREATMENT OP TETANUS 


out mth 3 per cent, alcoholic solution of iodine, and looselj^ filled 
with gauze soaked in the same .solution, and injection of antitoxin 
will be made (1500 to 3000 units) deeply into the muscular tissues 
around the wound. Continuous proctoclysis, as used in cases of 
peritonitis, udll be given; and by mouth or in the rectal fluid will 
be administered effective doses of chloral and bromides, at appro- 
priate intervals. Feeding vdll be enforced, by the nasal tube 
passed under chloroform anesthesia, if necessary. During the 
course of the first day a moderate amount of antitoxin will be 
administered intravenously; probably 10,000 units will suffice. 

The intraneural and intraspinal injections of antitoxin will be 
repeated daily, under chloroform anesthesia, until marked decrease 
in spasticity occurs. Every twelve hours, or less often, a moderate 
amount of antitoxin will be injected intravenously, or even sub- 
cutaneously, so as to neutralize the circulating toxins; but the 
main reliance will be placed on intraneural and intraspinal injec- 
tions. The administration of spinal depressants will be continued 
so long as they are indicated ; a comatose state or muscular relaxa- 
tion naturally are contraindications. The wound will be dressed 
daily, as above described, until a healthy granulating surface is 
obtained. 

With such treatment, commenced within twelve hours of the 
first appearance of symptoms of tetanus, we believe the mortality 
of the disease should not be over 20 per cent. Of the 11 patients 
under our own care, 7 have recovered and only 4 died, a mortality 
of 36,36 per cent. One of these deaths was caused by an overdose 
of magnesium sulphate; this patient did not come under observa- 
tion until the fourth day of the disease, and none of the other 
fatal cases came under our care until more than twenty-four hours 
after the onset of indubitable symptoms of tetanus. 

■5 Since the above was written, one of us (Ashhurst) has seen in consultation with Dr. George 
W. Norris, in his ward at the Pennsylvania Hospital, another case of tetanus: 

Samuel W., negro, aged twenty-seven years, crushed his right index finger shortly before 
December 1, 1912. The skin was broken, but he bandaged the finger himself and never had 
any medical treatment for it. About December 8 or 9 he began to complain of stiffness and 
soreness in jaws, but never had any difficulty in swallowing. On December 11 he complained 
of a “ball of wind” in the epigastrium, which caused oppression and dyspnea (tetanus of dia- 
phragm?). Dyspnea became more urgent on December 13, and on December 14 he went to 
bed. About this time he noticed that his legs were getting stiff (descending tetanus), and could 
be flexed only with great difficulty; no complaint of pain. Since December 15 he has had fre- 
quent spasms (ten to twelve daily) of his abdominal and thoracic muscles. These caused no 
pain, but made it more difficult to breathe. His legs were not weak, and would support him if 
he was helped up into a standing position; but they were perfectly helpless from rigidity. 

Admitted to the Pennsj’lvania Hospital December 17, evening. Receiving ward diagnosis: 
Transrerse myelitis. Transferred to medical ward and seen by Dr. Norris on the morning of 
December 18, when a diagnosis of tetanus was made. 

First seen bj' Dr. Ashhurst at 6.45 p.M. on December IS. No antitetanic treatment had been 
instituted. During the day the patient had had five general convulsions, and had a sixth con- 
■vmlsion while under observation. IVhen examined after this con\’ulsion there was no trismus; 
the head was retracted and the lumbar spine arched; the lower extremities were in full extension 
and very rigid. The patient lay on his right side. 

December 18. At 7.30 p.M., under chloroform anesthesia, lumbar puncture was done: there 
was a verj- free flow of spinal fluid, which was under great tension (5 c.c. were sent to the labora- 



ASHHURST, JOHN: THE RATIONAL TREAT1\1ENT OP TETANUS 93 

The following table gives the general mortality in some recent 
series of consecutive cases of tetanus: 


(Consecutive) Case Reports. 



Cases. 

Recovered. 

Died. 

Mortality. 

Bockenheimer (1908) .... 

. 20 

3 

17 

85.0 per cent. 

Busch (1907) 

. 30 

9 

21 

70.0 per cent. 

Episcopal Hospital (1905 to 1912) 

. 23 

10 

13 

56 .,5 per cent. 

Fricker (1897 to 1902) . . . 

. 22 

9 

13 

55 . 5 per cent. 

Hessert (1909) 

15 

5 

10 

66,6 per cent. 

Hofmann (1907) 

30 

20 

10 

33.3 per cent. 

Huber (1912) 

38 

7 

31 

81.5 per cent. 

Hutchings (1909) 

6 

4 

2 

33.3 per cent. 

Jacobson and Pease (1906) 

. 191 

58 

133 

69 . 6 per cent. 

Kintzing (1911) 

7 

7 

0 


Magula (1911) 

33 

11 

21 

66.7 per cent. 

Simon (1911) 

6 

4 

2 

33 . 3 per cent. 

Suter (1905) 

14 

2 

12 

85.7 per cent. 


tory for e.’camination as to presence of tetanus toxin, but through some misunderstanding this 
examination was not made; a culture ot the fluid remained sterile); SOOO units of antitoxin 
(15 o.c.) were injected into the subdural space of the cord; this was all the antitoxin available, 
at that time. The patient was given chloral, grains xv, and potassium bromide, grains xxx, every 
three hours by mouth. 

At midnight the patient was seen again, and 15,000 units of antitoxin were given intravenously 
in a pint and a half of saline solution. No more convulsions had occurred. 

December 19. The next morning the patient was better. There had been no more convul- 
sions, but many opistliotonio spasms. At 7.30 a.ji. he was given a sponge bath, and after this 
ho had two general convulsions. There was more trismus than at any time, and the tongue could 
just be protruded between the teeth. During the forenoon ebioroiorm was again administered, 
and Dr. Norris attempted to give antitoxin intraspinally, but was unable to introduce the needle. 
Therefore 13,500 units were given intravenously in six ounces of saline solution. This made a 
total of 36,500 units administered in an effective manner within si.xteen hours of the time the 
patient came under surgical observation. No intraneural injections were given, .as no facilities 
existed for a surgical operation. 

The patient was seen again at 7 p.m. There had been no convulsions all daja His muscles 
were quite relaxed. The chloral was reduced. 

December 20. Has had no more conamisions; only a few, and not severe, spasms. Has taken 
food well. Chloral stopped. 

December 21. Perfectly relaxed. Cured of tetanus. Clear in head and converses normally, 
but has pneumonia at rigiit base (probably from inspiration of food) and is quite weak. 

December 22. Died at night from pneumonia; temperature, 101° P.; pulse, 148; respira- 
tions, 40. 


VOL. MO, .\o. 1.— jutv, 1913 


4 



Cases op Tetanus at Episcopal Hospital 1905 to 1912. 


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9S ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 


ANALYSIS OF EPISCOPAL HOSPITAL CASES. 

Twenty-three cases. Mortality, 56.5 per cent. 

10 recovered (3, 6, 8, 9, 10, 11, 14, 15, 20, 23). 

13 died (1, 2, 4, 5, 7, 12, 13, 16, 17, IS, 19, 21, 22). 

Incubation under ten days, 11 cases. Mortality, 63.6 per cent. 

4 recovered (3, 6, 10, 23). 

7 died (2, 7, 13, 16, 19, 21, 22). 

Incubation over ten days, 12 cases. Mortality, 50 per cent. 

6 recovered (8, 9, li, 14, 15, 20). 

6 died (1, 4, 5, 12, 17, 18). 

Efficient treatment within twelve hours of symptoms, 5 cases. 
Mortality, 20 per cent. 

4 recovered (9, 10, mild cases; 11, 23, severe cases). 

1 died (17, severe case). 

No efficient treatment within twelve hours of symptoms, 18 
cases. Mortality, 66.6 per cent. 

6 recovered (3, 6, 8, 14, 15, 20, all mild cases). 

12 died (1, 2, 4, 7, 12, 13, 16, 18, 19, 21, 22, severe cases; 5, 
mild case). 

Less severe type of disease, 9 cases. Mortality, 11 per cent. 

8 recovered (3, 6, 8, 9, 10, 14, 15, 20). 

1 died (5). 

Very severe type of disease, 14 cases. Mortality, 85.7 per cent. 

2 recovered (11, 23). 

12 died (1, 2, 4, 7, 12, 13, 16, 17, 18, 19, 21, 22). 

Wounds of upper extremitjy 9 cases. Mortality, 89 per cent. 
Wounds of lower extremity, 8 cases. Mortality, 50 per cent. 
Wounds of trunk, 3 cases. Mortality, 33.3 per cent 
Wounds of head, 3 cases. Mortality, 0.0 per cent. 

Antitoxin used in all 23 cases. 

Efficiently as to method and quantity in 12 cases. Mortality, 
46.1 per cent. 

7 recovered (3, 8, 9, 10, 11, 15, 23). 

5 died (13, 16, 17, IS, 19). 

Inefficiently in 11 cases. Mortality, 72.7 per cent. 

3 recovered (6, 14, 20). 

8 died (1, 2, 4, 5, 7, 12, 21, 22). 


CASE HISTORIES. 

Case 1. — Edward C., aged twenty-three years. Admitted, 
October 9, 1905. Discharged, October 10, 1905. Died. Service 
of Dr. Sinlder. Attending, Drs. Sinlder and Sweeney. 

Left arm was vaccinated September 18; it began to get sore in 
four days, and patient had slight nausea. Then felt well until 
October 7 (nineteen days after vaccination), when he had head- 



ASHHURST, JOHN : THE RATIONAL TREATJIENT OF TETANUS 99 

ache, pain in back of neck, nausea, and vomiting, with beginning 
trismus. Family physician dressed arm and advised removal to 
hospital', but patient stayed home two days longer. 

On Admission (third day after first sj^mptoms) there was trismus 
and retraction of head, abdomen scaphoid and rigid. _ On arm a 
slough the size of a silver dollar, baring muscle,' which is black 
and sloughing and surrounded by area of necrotic fat; no pus. 

October 9. On admission, given morph, sulph., gr._ |, at 9 a.m., 
4 P.M., and 9 P.M.; tetanus antitoxin, 20 c.c. in morning, repeated 
in afternoon, hypodermically. At 6 p.m. there was suggestion of 

a convulsion. . . 

October 10. Convulsion at 6 a.m. for four minutes. _ Legs rigid, 
slight opisthotonos; spasms at approach of anyone. Given potass, 
bromide, gr. xl, and chloral hydrate, gr. xwx, by enema; also morph, 
sulph. at 3 A.M. and 4 a.m., hj'podermically. Also 20 c.c. of anti- 
toxin. Died, 8 a.m. 



Fig. 1. — Typical temperature chart of fatal case. (Case 2.) 


Case 2. — George V., schoolboy (age unknown), under twelve 
years. Admitted, June 4, 1906. Discharged, June 6, 1906. Died. 
Service of Dr. Neilson. Attending, Dr. Owen. 

On May 26, was Idcked by a horse, sustaining green-stick frac- 
ture of left forearm, with lacerations of skin; not a compound 
fracture. Treated in surgical dispensary for the next week. On 
June 2 felt ill, went to bed, but was up and about the next day. 






100 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

On June 4 complained of had 'pain in affected arm, trismus and 
headache; had one or two slight convulsions, and was sent to the 
hospital 

On Admission (same day as first symptoms). Jaws could be 
opened one-half inch; neck was stiff, abdomen rigid, legs stiff, but 
not rigid. Knee-jerks present on both sides, also ankle clonus. 
Is able to talk, has no pain until disturbed, then becomes 
temporarily rigid. 

J une 4. On admission, given bromide, gr. xv, and chloral hydrate, 
gr. V, every four hours by rectum. Given 30 c.c. of tetanus anti- 
toxin every three or four hours, hypodermically. 

June 5. Dose of tetanus antitoxin increased to 60 c.c. every 
four hours hypodermically. Given in all 330 c.c. of antitoxin 
hypodermically. 

June 6. Given 10 c.c. of antitoxin (1500 units) intraspinally, at 
12.30 A.M. Died at 3.15 a.m., “evidently from sudden paralysis 
of respiratory centres.” 

Case 3. — Steven C., aged forty-eight years. Adrnitted, August 
6, 1906. Discharged, September 2, 1906. Recovered. Service of 
Dr. Denver. Attending, Drs. Weber and Aufhammer. 

Right hand caught in machinery on morning of admission; 
diagnosis on admission, compound fracture of wrist-joint, badly 
lacerated and contused. Wound did fairly well, 

August 15. (Nine days after injury.) Developed trismus and 
some stiffness of muscles of neck. 

August 16 Given sodium bromide, gr. x, and chloral' hydrate, 
gr. X, every six hours; also tetanus antitoxin, 30 c.c. every two 
hours hypodermically. 

August 17. Given sodium bromide, gr. xv, and chloral, gr. lx, 
every six hours; also antitoxin as before. 

August 19. Given sodium bromide, gr. xx, and chloral, gr. x, 
every six hours. 

August 20. Sodium bromide, gr. xv, and chloral, gr. x, every 
six hours. Same treatment continued until 

August 23. When patient developed delirium tremens, pneu- 
monia, and later empyema. Transferred to surgical ward. Cured 
of tetanus, September 2, 1906. Died after many months as result 
of empyema. 

Case 4. — James McD., aged forty-four j^ears. Admitted, March 
5, 1908. Discharged, March 6, 1908. Service of Dr. Davis. Attend- 
ing, Drs. Davis and Brown. Died. 

Eight weeks ago, while chopping down a tree, patient lacerated 
his right great toe inth an axe. Came to surgical dispensarj^ five 
weeks later (three weeks ago). On March 2, began to have pain 
in back; pain and stiffness increased. 

March 3. Neck and jaw became stiff. This morning the jaw 
became fixed. No convidsions. Walked to hospital. 



ASHIIURST, JOHN; THE RATIONAL TREATMENT OF TETANUS 101 


On Admission. Jaws can be opened one-quarter of an inch; 
muscles stiff and spastic. Dr, Davis amputated the toe under 
ether. Patient had a convulsion during the operation. 

Antitoxin, 3000 units, at 6 P.M., subcutaneously; antitoxin, 
3000 units, at 10.30 p.m., subcutaneously. 

March 6. Antitoxin, 3000 units, at 4 A.M., subcutaneously; 
antitoxin, 3000 units, at 9 a.m., subcutaneously. At 10 a.m. the 
patient died of asphyxia in conndsions. 

Case 5. — Katie M., aged twenty-six years. Admitted, May 31, 
1908, at 12.30 a.m. Discharged, June 30, 1908, 5.35 p.m. Died. 
Service of Dr. Neilson. Attending, Drs. Js^eilson and Price. 

Admitted for compound fracture of left tibia and fibula, simple 
fracture of right tibia and fibula. Injured by explosion in naphtha 
launch on the Delaware River, all sixteen passengers being thrown 
into the river. Patient badly shocked. 

June 20. For some days has had slight spasticity of facial muscles 
and tendency to sardonic grin, more noticeable in the morning; 
some stiffness of muscles at back of neck; no convulsions. Sodium 
bromide, gr. xx, and chloral, .gr. v, every four hours. 

June 21. Jaws, back, and neck still stiff; facial muscles, 
better. 

June 22. Trismus continues, but is no worse; swallows easily; 
says she bites her tongue whenever she sleeps. 

June 23. Patient not so well; jaws stiff er; twitches more; diffi- 
culty in swallowing; neck stiff and painful. Antitoxin, 3000 units, 
twice (6000 in all, two hours apart). Sodium bromide, gr. xx, 
and chloral hydrate, gr. x, every four hours. Morph, sulph., gr. 

and atropine sulphate, gr. yst, every six hours. 

June 24. Antitoxin, 3000, t. i. d. (9000). Has a slight general 
convulsion each time disturbed. 

June 25. Temperature, pulse, and respiration, rising. Tempera- 
ture, 106.4° F.; comatose; sedatives stopped; sponged, p. r. n. 

June 26. Conscious and restless; sedatives again. 

June 27. Less restless. Antitoxin, 3000 units, at 5.30 p.m. 

June 28. Comatose; Cheyne-Stokes respiration. 

June 29. Comatose; did not move all day. 

June 30. Comatose; died at 5.35 p.m. 


Case 6. — Leslie R. E., aged thirteen years. Admitted, August 
12, 1908. Discharged, August 23, 1908. Recovered. Service of 
Dr. Deaver. Attending, Dr. Corson. 


Six days before admission was struck behind the right ear with 
a rusty knife, which stuck in his neck; this penetrated about one 
and one-half inches, and was withdravm vdth difficulty; small 
wound (punctured by thin blade) ; taken to another hospital where 
suture was put in wound and no attempt at drainage made. Began 
to feel stiffness at back of neck, headache,aMd=fe3ter, and twitchiim 
of face muscles four days later pRnlisMp.u). 







102 ’ASimuRSTj JOHN: the rational treatment of tetanus 

On Admission. Small crust over wound behind right ear, with 
one silkworm gut suture; this was removed, wound opened and 
packed. Antitoxin, 1500 units, hypodermically. 

August 13. Still slight stiffness of jaws. Antitoxin, 1500 units, 
hypodermically. 

August 14. All muscular stiffness gone. 

August 20. Out of bed. 

August 23. Discharged. Diagnosis of tetanus considered posi- 
tive at the time in the opinion of Dr. George Thomas (family 
physician) and Dr. Deaver. 

November 17, 1912. Returned for examination. Has had no 
symptoms since. In perfect health. Small cicatrix, scarcely visible, 
over base of right mastoid process. 

Case 7. — ^Andrew H., aged thirty-five years. Admitted, August 
28, 1908. Discharged, August 30, 1908. Died. Service of Dr. 
Deaver. Attending, Drs. Deaver and Corson. 

Ran a rusty nail into his foot on August 24; came to the dis- 
pensary on August 27, because foot swelled up. Wound was 
opened “clear through,” but is still painful, and is kept in the 
ward because he lives at a distance. 

August 29. At 4 p.iM. the patient suddenly developed stiffness 
of jaws and back of neck. Very much excited and irritable. Foot 
laid freely open where the nail had penetrated. Carbolized and 
packed. Antitoxin, 2000 units, subcutaneously. Sodium bromide, 
gr. XX, and chloral, gr. x, every six hours. 

August 30. More opisthotonos; very restless. Antitoxin, 3000 
units, hypodermically. Died at 10 p.m. 

Case 8. — Joseph (4., aged thirty-four years. Admitted, Septem- 
ber 28, 1908. Discharged, November 3, 1908. Recovered. Service 
of Dr. Frazier. Attending, Drs. Ashhurst and Corson. . 

Four days before admission was thrown from a wagon and was 
dragged, receiving a brush burn of the abdomen. Referred to 
ward as recent accident, because of hematoma of the left thigh. 

October 6. Hematoma incised. 

October 7. Jaws stiff. Antitoxin, 1500 units, subcutane- 
ously. 

October 8. Jaws still stiff; no pain except when he eats; a little 
tvdtching at night. 

October 9. Stiffness in abdomen and across lower back. Jaws 
can be opened one-half inch. Headache all night. Antitoxin, 
1500 units. Transferred to isolation ward. 

October 10. At 2.30 a.m. had convulsion, tetanic in type. Threw 
his head back and had opisthotonos. Given chloroform and 4 c.c. 
of slightly turbid cerebrospinal fluid withdrawn and 3000 units 
of antitoxin injected. Brush burn curetted. Sodium bromide, 
gr. XX, and chloral, gr. xx, every six hours; 9 a.m., patient rather 
delirious; a little nauseated; back of neck stiff. Antitoxin, 3000 



ASHIIURST, JOIIN: THE RATIONAL TREATIMENT OF TETANUS 103 

units, every four hours, subcutaneously. (Stopped October 17.) 
10 A.M., jaws open one-quarter inch; some pain in head. 

October 12. Headache ceased. 

October 13. Abdomen much less rigid. Neck limber and back 
much less rigid. 

October 14. Jaws open one inch. 

October 17. Antitoxin reduced to 1500 units, every four hours. 
Sedatives decreased. , 

October 21. Slightly comatose. 

October 24. Abdomen soft. 

October 31. Sent back to ward as recovered. 

Case 9.— Thomas W., aged fifty-five years. Admitted, Septem- 
ber 23, 1908. Discharged, December 5, 1908. Recovered. Service 
of Dr. Frazier. Attending, Drs. Ashhurst and Aufhammer. 

A gunshot wound of the right temporal region, with a fracture 
of the orbit and rupture of the eyeball. Dr. G. 0, Ring in consul- 
tation for the ocular condition. 

October 20. Four weeks after injury. Complains of stiffness of 
jaws, says it started October 19; 1500 units antitoxin, hj^poder- 
mically. Sodium bromide, gr. xx, every six hours. Transferred 
to isolation ward. 

October 21. Antitoxin, 1500 units, every four hours. 

October 23. Antitoxin, 1500 units, every eight hours. 

October 24. Antitoxin, 1500 units, every ten hours. 

October 26. Antitoxin, 1500 units, every twelve hours. 

October 27. Antitoxin, 1500 units, every sixteen hours. Cured 
of tetanus, October 27, and transferred to convalescent ward, 
where Dr. Ring enucleated eyeball on November 17. 

Case 10. — John S., aged forty-nine years. Admitted, November 
12, 1908. Discharged, Deeember 8, 1908. Recovered. Service 
of Dr. Frazier. Attending, Drs. Ashhurst and Gracey. 

Chief complaint. Stiffness of jaws and sore foot. 

November 4. The patient ran a rusty nail through the shoe 
into his foot. Pulled the nail out and washed the foot with 
chloride of lime and soda ash and put ham fat on it. The foot 
began to swell, and he used iodine and arnica. One week after 
injury to the foot jaws began to stiffen so that he could not eat. 
Came to the dispensary and was sent to the ward November 12. 

On Admission. Jaws can be opened one-half inch; right leg is 
rigid and painful. Has had spasms of jaws, which snap shut and 
cannot be opened. 

November 12. At 7 p.m., under chloroform, 3000 units of 
tetanus antitoxin was injected into the subdural space of the cord; 
the foot, which meanwhile had healed, was reopened through the 
plantar fascia widely, and 1500 units of antitoxin injected deeply 
into muscles of foot; 1500 units of antitoxin injected, everj'' four 
hours, hypodermically for five doses. 



104 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

Svmmary (until morning of November 14). First day: Anti- 
toxin intraspinally, 3000 units; into wound, 1500 units; subcuta- 
neously, 7500 units. Total 12,000 units. Calomel, gr. ss.; mag. 
sulph., oz. j; whisky, fl. oz. iij; chloral, gr. lx; potassium bromide, 
gr. cxx. 

November 14 and 15. Second day: Antitoxin, 13,500 units, 
subcutaneousl}’; cliloral, gr. lx; potassium bromide, gr. clx; whisky, 
fl. oz. vii; calomel, gr. j; mag. sulph., oz. ]. 

November 15. Third day: Antitoxin, 4500 units, subcuta- 
neously; potassium bromide, gr. Ixxx; whisky, fl. oz. vss. 

November 16. Fourth day: No antitoxin. No sedatives. 
Patient transferred to men’s medical ward for bronchitis. 

November 26. Patient given 3000 units of antitoxin hypo- 
dermically for pain in jaws. No further symptoms of tetanus. 

November 17, 1912. Returns for examination, four years after 
recover^L Says for two jmars right foot and leg troubled him, 
being sometimes weak, dragging as he walked, but at other times 
had no trouble. In December, 1910, on stepping suddenly off a 
trolley car, right leg became spastic, jaws locked, and patient had 
to grasp a street post to prevent falling. Under great muscular 
effort he managed after several minutes to open his. mouth. No 
such attack since; but occasionally had shooting pains in leg and 
up the spine to the head. Has been under medical treatment for 
the past year, and has had no trouble vdth his leg during that time. 
Until the last year has had to be laid off work for several weeks 
at a time once or twice annually. Physical examination is negative. 
Linear, supple scar on sole of right foot, two inches long. Knee- 
jerks normal. No paresis or spasticity. 

Case 11. — ^Thomas C., aged nineteen years. Admitted, Decem- 
ber 12, 1908. Discharged, December 31, 1908. Recovered. Ser- 
vice of Dr. Frazier. Attending, Drs. Ashhurst and Gracey. 

November 30. While running along floor of mill, soaked in 
machine oil, where he works, a large splinter ran through a hole 
in his shoe and penetrated the sole of his left foot near the head 
of the metatarsal of the great toe. The patient went to the dis- 
pensary, where the wound was cauterized and drained. Second 
visit to the dispensary two days later, but made no further visits, 
the patient himself removing catgut drainage that had been intro- 
duced. Was away from his work for one week. 

December 17. The eighteenth day after the injury. Patient 
did not feel well and his jaws were sore and stiff. Took to his bed 
on December 18. That night he says his back muscles contracted 
until he rested only on the back of his head and heels. Was sent 
to the hospital by family phj^sician who saw him in the morning. 

On Admission. Jaws can be opened one-half inch; considerable 
stiffness of muscles of the back of neck and some stiffness of the 
back muscles; abdomen markedly rigid and a tendency to stiffness 



ASHHUESTj JOHN: THE RATIONAL TREATjMENT OF TETANUS 105 

of the legs. Wound on foot has counteropening for drainage, two 
inches distant. As soon as possible after admission patient was 
given chloroform and 3000 units of antitoxin injected intraspinallj^; 
the wound in the foot Avas opened deeply through the plantar 
fascia, scraped out and packed with gauze soaked in iodine, 1 to 
3 of water. Three splinters removed from the wound. Culture 
on blood serum and an anaerobic culture made (streptococci; no 
Bacillus tetani). 



Fia. 2. — Typical temperature chart of severe case arrested promptly with ultimate recovery. 

(Case 11.) 



Fig. S.-Granulatins ^ ound through which .antitoxin had been injected into the sciatic nerve. 
V ound left open for subsequent injections, avhich. however, were not necessary. (Case 11.) 

December 20. Jaws opened one find one-eighth inches; not so 
stiff in the neck muscles. Chloral hydrate, gr. x, and potassium 
bromide, gr. xx, every three hours. Total chloral hydrate, gr. lx, 











106 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

and potassium bromide, gr. cxx. At 3.30 p.m., 750 units of anti- 
toxin was injected into the sciatic nerve, which was exposed by 
»an incision under chloroform, and 750 units injected around the 
wound in the foot. 

December 21. Jaws opened one and three-quarter inches. 
Summary: No antitoxin; chloral hydrate, gr. c; potassium bro- 
mide, gr. clx. 

December 22. Summary: No antitoxin; chloral hydrate, gr. 
Ixxx; potassium bromide, gr. clx. 

December 23. Summary: No antitoxin; chloral hydrate, gr. 1; 
potassium bromide, gr. c. 

December 24. Summary: No antitoxin; chloral, gr. xxxv; 
potassium bromide, gr. Ixx. 

December 25. Summary: No antitoxin; chloral, gr. xx; potas- 
sium bromide, gr. 1. Patient is now convalescent. Chloral and 
bromides continued in diminishing doses for three days longer. 

December 31. Patient transferred to surgical ward as cured of 
tetanus. 

Case 12. — Francis C., aged sixty-three years. Admitted, Oc- 
tober 16, 1909. Discharged, October 19, 1909. Died. Service 
of Dr. Frazier. Attending, Drs. Ashhurst and Hopper. 

September 28. Fingers of the right hand badly lacerated in a 
picker in a woollen mill. Patient treated in the dispensary and 
attending daily. 

October 15. Patient felt jaws becoming stiff and sent for the 
ambulance twelve hours later. 

On Admission. October 16. General physique poor; jaws stiff; 
opisthotonos; abdominal muscles board-like; neck retracted; 
reflexes, especially the patellar, markedly increased. Chloral, 
gr. X, and sodium bromide, gr. xx, every two hours. 

October 17. General condition poor. Under chloroform lumbar 
puncture was made and 1500 units of antitoxin injected. All the 
fingers of the right hand amputated at tlie metacarpal joint; even 
under chloroform the marked lordosis could not 'be made to dis- 
appear. Chloretone, gr. xxx,* every two hours. Stopped the sodium 
bromide and chloral. 

October 18. Patient semicomatose; heart bad. p.m. Heart 
weakening. No increase of rigidity. 

October 19. Patient died at 4 a.m. 

Case 13. — Margaret D., aged eleven years. Admitted, Novem- 
ber 20, 1909. Discharged, November 22, 1909. Died. Service of 
Dr. Frazier. Attending, Drs. Ashhurst and Hopper. 

November 11. Patient fell and abraded right knee. Was treated 
at home and became infected. Jaws became stiff in the morning 
of November 19, but went to school and on return again called 
mother’s attention to her stiff jaws. Went to bed and slept well. 
In the morning (November 20) jaws were rigidly clenched, and 



ASHHUrtST, JOHN : THE KATIONAL TREATMENT OF TETANUS 10 1 

when she tried to move or be moved, she became very rigid; she 
had pain in jaws, neck,' and back. Her family physician saw her, 
said she had symptoms of lockjaw, left some medicine and asked 
to be called on the phone in the evening. When he heard her 
condition then he sent a note asking for the ambulance and her 
admission to the hospital. 



Fia. 4. — Opisthotonos. Death six hours later in convulsions. (Case 18.) 


On Admission (November 20, 10.30 p.m.). Jaws were set, head 
retracted, legs extended and rigid; moderate lordosis; board-like 
scaphoid abdomen; mind clear; reflexes all increased; suppurative 
abrasion over tubercle of the right tibia covered with a bread 
poultice. 

November 21, 12.30 a.m. (two hours after admission). Patient 
was operated upon (chloroformed.) The anterior crural and obtu- 
rator and sciatic nerves were exposed and 750 units of antitoxin 
injected into each of anterior crural and obturator and 1500 units 
into sciatic; about 1500 units injected around wound in the leg, 
after disinfecting it and swabbing it out vdth 3 per cent, alcoholic 
solution of iodine. Continuous saline proetoelysis. Chloretone, 
gr. XV, every four hours by mouth. Chloral hydrate, gr. xx, and 
sodium bromide, gr. xxx, every two hours by rectum in saline 
proctoclysis. During the morning (November 21) the patient was 
quiet, jaws slightlj'^ less rigid and can now open one-quarter of an 
inch. Seems better generally. 

2.30 P.M. Incisions reopened and same dose of antitoxin injected 
into anterior crural, obturator, and sciatic nerves; 1500 units of 
antitoxin given intraspinally under chloroform. 

4.30 P.M. Teeth can be separated further. 

/.30 p.m. Patient not so well. Temperature, pulse, and re.spi ra- 
tion all rising. 



108 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

10.30 P.M. Patient restless. Jaws still less rigid. Clonic con- 
tractions of muscles of back and legs every few minutes; 1500 
units of antitoxin hypodermically. 

November 22, 1.30 A. M. No change. 

9.30 A.M. Patient weaker. Cliloretone stopped. Tincture of 

digitalis, minims v. Camphorated oil, minims xx, every four 
hours. , ^ ; 

12.00';^T:r""AT[tito'xin as above into nerves under chloroform; 
none giVen' intraspinally. 

3.00 P.M. Patient has been comatose ever since chloroform 
this noon. Respirations shalloAV and labored. Pulse better. 

6.30 P.M. Patient died, in relaxation. 

C.ASE 14. — Sarah McV., aged forty-five years. Admitted, 
February 4, 1910. Discharged, February 19, 1910. Recovered. 
Service of Dr. E. J. Morris. Attending, Drs. Ashhurst and Siner. 

January 23 (twelve days before admission). "VSfiien pregnant 
three months, fell dovm stairs in bare feet and sprained back and 
received small lacerated wound between fourth and fifth right 
toes; no other injuries. The interdigital cleft became very painful 
the next day and the foot began to swell. Patient treated the 
foot at home for ten days and then on February 2, came to the 
surgical dispensary and was dressed. Returned two days later 
and complained of pain on opening mouth and stiffness of jaws. 
Referred at once to isolation by Dr. Ashhurst, after renewed 
antiseptic treatment of wound mth iodine (3 per cent.). 

On Admission, February 4. Chief complaint: Stiffness of jaws 
and neck and wound of right foot. 

Examination. Reflexes slightly increased; no ankle clonus or 
Babinski; abdomen not rigid; patient three months pregnant; 
3000 units of antitoxin subcutaneously on admission. Potassium 
bromide, gr. xxx, and chloral hydrate, gr. xv, every four hours. 
Mag. sulph., oz. ss. 

February 5. Patient complains of headache, backache, and 
muscular pains all over; abdomen somewhat tender and rigid. 
Reflexes slightly increased; 1500 units of antitoxin, one-half around 
wound in foot and one-half in abdominal wall, hypodermically. 
Bromides and chloral only t. i. d. 

February 6. Pains in pelvis; uterine bleeding all day, passing 
several large clots. 

Pelvic examination: Large soft cervix; fundus above pubis; 
os not dilated. 

February 7. At 2 a.m. a very profuse metrorrhagia. Os now 
patulous and placenta protruding. Uterus cleaned out Avith 
placental forceps and packed. Fluid exi;ract of viburnum pruni- 
folium, dram j every three hours. 

10.00 A.M. Patient in good condition. 



ASHHUEST, JOHN: THE KATIONAL TREATMENT OF TETANUS 109 

' February 8. Packs removed; 1500 units of antitoxin subcu- 
taneously. 

February 19. Patient has done well. Discharged today as 
cured of tetanus. 

Case 15— Mary S., negro, aged twenty-three years. Admitted, 
February 21, 1910. Discharged, March 8, 1910. Recovered. 
Service of Dr. Neilson. Attending, Drs. Ashhurst and Siner. _ 

January 26, at 2 a.m., while walking on the street, the patient 
was struck on the head by a brick, causing a slight laceration. 
She was taken in the ambulance to another hospital, where the 
laceration was sutured and the patient discharged one hour later. 
Returned on the tenth day and had the sutures removed. She 
says that at that time there was a small tender swelling in the 
wound. 

February 14. One week before admission, and nineteen days 
after the wound, the patient’s jaws gradually became painful, 
and she began to have difficulty in opening her mouth. The condi- 
tion gradually grew worse, and she can now barely separate her 
jaws one-quarter of an inch, with much pain. 

071 Admission, February 21. Temperature, 100° F. Chief 
complaint is stiffness of jaws. Postauricular lymph nodes on 
right enlarged. Cicatrix from recent wound on scalp, near inion; 
below is a small, tender lump. Abdomen a little tender. Some 
rigidity of muscles of back and neck. Patellar reflexes greatly 
exaggerated on the right and increased on the left. No ankle 
clonus or Babinski. Mag. sulph., oz. ss., stat. Antitoxin, 3000 
units subcutaneously on admission' and 1500 units intraspinally. 
Potassium bromide, gr. xxx, and chloral hydrate, gr. vii, every 
three hours by mouth. Hyoscine, gr. hypodermically, 3 p.m. 
and 11 P.M. Abscess on scalp opened. 

February 22. Antitoxin 3000 units subcutaneously at 10 a.m. 
Sedatives as before. Patient’s condition not so good. Jaws nearly 
closed. Neck and back somewhat rigid. Stuporous, and mind 
wanders. More pain in head. Antitoxin, 3000 units, at 4 P.M., 
subcutaneously; 1500 units at 8 p.m., when there was some improve- 
ment. Jaws not so rigid. 

February 23. 10 a.m., 2 p.m., and 8 p.m., 1500 units of antitoxin 
subcutaneously. Condition the same. Morphine, gr. Great 
pain, worse in the back. Sedatives as before. 

February 24, a.m., and p.m., 1500 units of antitoxin subcuta- 
neously. Jaws opened one-half inch in the morning, and open 
one inch by evening. Sedatives as before. 

February 25. No more sedatives after February 24; 1500 units 
of ^ antitoxin subcutaneously. Tincture of digitalis, minims x, 
t. i. d. 

February 26, 3000 units of antitoxin subcutaneously. Pains 
in lower jaw. 



110 ASHHUKST, JOHN: THE RATIONAL TREATjMENT OE TETANUS 

February 27. No antitoxin after this date. 

February 28. Patient can flex neck until chin is within two 
inches of chest. 

■ March 1. Can make chin touch chest. 

March 2. Sat up in bed for first time. Soft diet for first time. 

March 3. In chair for one-half hour. 

March 4. Jaws open three-eighths of an inch. 

March 5. In chair for two hours. 

March 6. Patient walked a little. 

March 7. Jaws can be opened one-half inch. Neck still some- 
what rigid, and when it is flexed until chiiiv touches sternum she 
has some pain in the back. 

March 8. Discharged as cured. 

Case 16. — Charles M., aged eight years. Admitted, July 17, 
1910. Discharged, July 20, 1910. Died. Service of Dr. Deaver. 
Attending, Dr. Griffith. 

July 5. Was cut on right thumb by hatchet. Wound was 
dressed in dispensarj^ using three sutures. No symptoms until 
Friday evening, July 15, when he complained of a little difficulty 
in swallowing. On July 16, felt all right. On July 17, before 
admission, had a spasm which lasted only a few minutes. 

On Admission. Patient perfectly relaxed, vdth the exception 
of some slight stiffness of jaws, and a sardonic grin, which was 
marked. Given 43,000 units of antitoxin hypodermically. Chloral, 
gr. ij, and potassium bromide, gr. vi, by mouth, every three hours. 
Had three spasms on day of admission, each lasting about three 
minutes, after which he was relaxed. 

July 18. Temperature higher. General condition not so good. 
Better toward night. Five spasms during the day, each about 
three minutes, one severe. Opisthotonos marked in last convul- 
sions and relaxation afterward not so complete. Sweating is 
marked; 5000 units of antitoxin, every three hours, for eight 
doses — 40,000 units, hypodermically. Bromide and chloral as 
before. 

July 19. General condition good, but jaws more locked. Some 
difficulty in swallowing. Pain in abdomen. Cyanosis of lips 
marked during spasms. Pour spasms todaj'^, one quite severe; 
20,000 units of antitoxin. 

July 20. General condition not so good. Jaws locked. Took 
a bad turn at 9 p.m. Temperature, 106° F. Died at 10.30 p.m. 

Case 17. — Harry F., aged seven years. Admitted, October 14, 
1910. Discharged, October 16, 1910. Died. Service of Dr. 
Frazier. Attending, Dr. Henneberger. 

Three weeks ago the patient Avas vaccinated, and Avas all right 
until the evening of October 13, AAdien malaise Avas noted and he 
complained of stiffness of back and soreness in jaAA^s. Brought 
to the hospital the next morning. 



ASIIHURST, JOHN: THE RATIONAL TREATMENT OF TET^VNUS 111 

Examination. Jaws somewhat stiff and unable^ to open mouth 
to full extent. Abdomen scaphoid, with great rigidity of abdominal 
muscles. The least tapping throws them into a tetanic contrac- 
tion; 5000 units of antitoxin, every four hours, subcutaneously. . 
Mag. sulph. (intraspinally), 2 c.c. of 25 per cent, solution a't 12.30 
A.M., October 15. 

October 16. Died at 1 a.m. Temperature, 104° F. Total 
amount of antitoxin in two days, 60,000 units subcutaneously. 

Case 18. — Minnie P., aged six years. Admitted, October 3, 
1910. Discharged, October 5, 1910. Died. Service of Dr. Frazier. 
Attending, Drs. Ashhurst and Griffith. 

September 7. Patient was vaccinated. She did well. Scab 
formed, which was knocked off at play and no other scab formed. 
Mother dressed the wound and a slight infection occurred, but 
healing proceeded normally from outside toward the centre. No 
untoward occurrence until October 1, when the child complained 
of mouth being sore, but was able to eat and play and slept well 
the night of October 1. Complained of mouth all of October 2, 
but could swallow, and went to Sunday school. On Monday, 
October 3, had malaise, and a weak spell in which she fell and 
received an ugly contusion on forehead. During the day she still 
complained of mouth being sore and some slight stiffness. General 
muscular rigidity noticed, and jaws were somewhat hard to open. 
Brought to the hospital on the night of October 3. 

On Admission. Contusion on the forehead the size of an orange, 
received by a fall in a weak spell. Opisthotonos; sardonic grin 
marked; angles of mouth drawn down; muscular rigidity marked; 
complains of pain in stomach; head retracted; had one slight con- 
vulsion before admission; sent to isolation ward, October 4; 5000 
units of antitoxin subcutaneously on admission. 

October 4.- Muscular rigidity marked; opisthotonos and sar- 
donic grin marked. Patient able to swallow. Had about two 
convulsions an hour today, but very slight. Potassium bromide, 
gr. lx, and chloral, gr. xxx, every three hours; 25,000 units of anti- 
toxin subcutaneously. 

October 5. Seen by Dr. Ashhurst on this date first; 10,000 
units of antitoxin intraspinally, and 15,000 units of antitoxin 
subcutaneously. Temperature rising. Convulsions increasing in 
severity. Patient is very restless, but able to take nourishment 
and medicine. A very severe convulsion at 3 p.m., followed by 
two slighter ones. Temperature, 106° F. At 4 p.m. several slight 
convulsions; breathing very labored; cold, clammy sweat. At 
5.30 p.:m. had three very severe convulsions, and died at 5.45 p.m. 
Temperature, 106.6° F. 

Case 19 Thomas B., aged six years. Admitted, January 4, 
1911. Discharged, January 7, 1911. Died. Service of Dr. Frazier. 
Attending, Drs. Ashhurst and Johnston. 



112 ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

Patient has a tapeworm, and has lost weight in the last few 
months. On December 23, while running in the street, he fell 
over a Belgian block, striking the palm of the right hand against 
a sharp piece of ice. A U-shaped laceration at the thenar emi- 
nence resulted, which bled very profusely. Was taken to another 
hospital, where two sutures were inserted, which controlled the 
hemorrhage. No antitoxin was given. 

January 1. It was first noticed that his jaw. was stiff and that 
he spoke like a child who wms tongue-tied. He was taken back 
to the same hospital, where, on account of the difficulty in opening 
the mouth and some patches on the tongue, diphtheria ivas sus- 
pected, but by mouth gag no membrane was found in the throat. 

January 4. A positive diagnosis of tetanus was made, and he 
wms sent to the Episcopal Hospital. 

On Admission. Teeth cannot be separated more than one-half 
inch. Face is wrinkled and angles of the mouth are drawm down 
and out in a sardonic grin. Depressors of the jaw become tense 
an any attempt to open mouth. When the patient is quiet, noth- 
ing abnormal is apparent. Neck muscles and those of the back 
are a little stiff, but no opisthotonos is present. Limbs are normal. 
A clean granulating ■wound on the right thenar eminence. 12 
midnight; 5000 units of antitoxin in right forearm. 

January 5, 4.00 a.m. Chloral hydrate, gr. iij. 

6.00 A.M. Slight convulsion. 

8.00 A.M. Jaws more rigid. 

9.00 A.M. 5000 units of antitoxin intraspinally. 

1.30 P.M. Potassium bromide, gr. v. Weaker. Delirious. 
Temperature, 104° F. 

4.00 P.M. Chloral hydrate, gr. iij. Patient sleeping. 

8.00 P.M. 5000 units of antitoxin subcutaneously. Potassium 
bromide, gr. v. 

12.00 P.M. Chloral, gr. iij. Temperature, 103.4° F. 

January 6, 4.00 a.m. Potassium bromide, gr. v. Temperature, 

100.2° F. 

12.00 M. 4500 units of antitoxin intraspinally. Seen by Dr. 
Ashhurst on this date first. 

1.00 p.Ai. Potassium bromide, gr. v. Temperature, 101.8° F. 
Chloral, gr. iiss by rectum. 

4.00 P.M. Sleeping quietly. 

8.00 P.M. Potassium bromide, gr. v, and chloral, gr. ijss by 
rectum, which •nms expelled. 

9.00 P.M. Potassium bromide, gr. v, and chloretone, gr. v. 

11.00 P.M. Sleeping. 

January 7, 1.00 a.ai. Chloretone, gr. v, because he awoke. 

3.00 A.Ai. Potassium bromide, gr. v. Temperature, 100.4° F. 

9.00 A.M. Potassium bromide, gr. v. 

12.00 M. Temperature, 101° F. 



ASHHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 113 

2.00 P.M. Mag. sulph., 3f grams in a 25 per cent, solution intra- 
spinally (7 c.c. of solution, clearly an overdose). 

3.00 P.M. Patient died in perfect relaxation. Probabl:^^ would 
have recovered if no magnesium sulphate had been given. 

Case 20. — Lillie S., aged twenty-seven years. Admitted, 
February 4, 1911. Discharged, February 22, 1911. Recovered. 
Service of Dr. Mutschler. Attending, Drs. Mutschler and J ohnston. 

Personal History. Has had one child. A prolonged and difficult 
labor vdth a laceration of the cervix. During the present gestation 
health has been good. Much better than previously. 

Present Condition. January 9. While at breakfast, had a sudden 
profuse hemorrhage. The uterus was evacuated by her physician. 
Improved for ten days, when a second sudden very severe hemor- 
rhage occurred. Two daj's later developed phlebitis in the left leg. 
Twenty-two days after delivery, four days before admission, patient 
began to have dull pains in muscles at back of neck, some difficulty 
in separating jaws, and slight pain on deglutition; all symptoms 
increased slowly in severity daily. On the day before admission 
had 5000 units of antitoxin subcutaneously. 

On Admission. Able to open incisor teeth only enough to admit 
tip of the index finger. This causes some pain in the neck. Some 
rigidity of muscles of back of neck, and pain on motion. Uterus 
felt just above pubis. 

Vaginal Examination. Small amount of brownish discharge, 
not especially foul. Cervix soft and lacerated; uterus enlarged, 
soft, not freely movable. Left leg uniformly increased in size; 
skin glistening, pits slightly on pressure. No pain in leg or on 
pressure over veins. 

February 4, 6.00 p.m. Chloretone, gr. x, every four hours. 

5.00 p.m. 5000 units of antitoxin in pectoral muscle. Left leg 
bandaged. 

February 5, S.OO a.m. Good bowel movement; appetite good; 
considerable thirst. Unable to open jaws enough to admit spoon. 

4.00 P.M. Phenol, 3 per cent., minims, xv, every two hours, 
hypodermically. 

5.00 P.M. Antitoxin, 5000 units, in right pectoral muscle. 
Patient very drowsy. Pain less in the neck. 

February 6, a.m. Patient very drowsy. 

4.00 P.M. Temperature, 104.8° F.; pulse, 136; respiration, 2S. 

5.00 P.Jr. All treatment stopped. Atropine sulphate, gr. y^; 
morph, sulph., gr. i, hypodermically. 

5.00 P.M. All appearances of intense sepsis. Completely 
relaxed. No pain anywhere. Infusion of digitalis, fl. dr., ij. En- 
teroclysis witli normal salt solution, to take one pint every three 
hours; with each pint, two drams infusion of digitalis. 

February t , 12.00 a.m. Antitoxin, 5000 units, subcutaneously. 
Return of pain and stiffness. Cliloretone, gr. x, every three hours. 



114 ASHIIURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 


February 10. 5000 units of antitoxin subcutaneously. 

February 11. 5000 units of antitoxin. 

February 13. 1500 units of antitoxin. 

February 22. Patient gradually improved until morning of 
February 22, when all tetanic symptoms had been absent for some 
days. On latter date, she had a severe uterine hemorrhage. Uterus 
packed, but patient failed rapidly. 

February 23, 12.15 a.m. Patient died. 

Case 21. — Poland P., aged eighteen years. Admitted, April 17, 
1911. Discharged, April 19, 1911. Died, Service of Dr, Neilson. 
Attending, Drs. Alexander and Campbell. 

April 10. While at work the patient had his hand caught in a 
machine; index, ring, and middle fingers cut. Middle and ring 
fingers amputated on the same day. Discharged on April 14. 
Returned to hospital on April 17, with tetanus. Jaws locked, pain 
in back, and stiffening of neck muscles. Hand is very much swollen, 
and has a very offensive odor. Stitches removed from fingers. 
Palm of hand opened up and one fiuidounce of pus removed. 
Several stab wounds made on back of hand; 5000 units of anti- 
toxin given subcutaneously every seventh hour. Hand dressed 
every day. Continuous 1 to 5000 bichloride dressing on hand. 

April 17. Antitoxin, 10,000 units, subcutaneously; whisky, 
oz. j, and morph, sulph., gr. J, 

April 18, A.M. Antitoxin, 5000 units, subcutaneously; whisky, 
oz. jss, and morph, sulph,, gr. J; p.m. Antitoxin, 10,000 units, 
subcutaneously; whisky, oz. ij, and morph, sulph., gr. J. 

April 19. Patient died at 3.55 a.m. 

Case 22. — John McD., aged eighteen years. Admitted, October 
3, 1911. Discharged, October 7, 1911. Died. Service of Dr. 
Frazier. Attending, Dr. MacFarland. 

September 20. The patient fell on a rusty hydrant stalk; the 
stem enterea the scrotum, and he walked home untreated. Later 
on the same day he came to the surgical dispensary, where he was 
not treated, but referred to ward, but did not stay. No antitoxin 
given. Thirteen days later was admitted to the hospital with 
symptoms of tetanus. (How long these had existed is not stated; 
probably two days.) 

On Admission. Well-developed adult male. Temperature, 
99° F.; pulse and respiration, normal. Has a sardonic grin; head 
retracted; slight opisthotonos; occasional attacks of general rigidity; 
jaws can be opened one-half inch; over pubis in the midline is an 
area the size of a quarter dollar, Avhich is tender, red, and inflamed; 
open wound on left side of scrotum, discharging yellow, purulent 
material. Probe reaches from here to area above pubis under the 
skin. 

Treatment. Under local anesthesia, incision made over tender 
area at pubis, and through-and-through drainage to scrotal wound 



ASHIIURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 115 

with rubber tube. Antitoxin, 14,000 units in 5000 doses subcu- 
taneously. Potassium bromide, dram ij, and urotropine, gr. x. 

October 4. Patient is worse. Frequent attacks of spasms, and 
pulse and respiration have increased. Antitoxin given every six 
hours, to make 20,000 units, subcutaneously. Frequent convul- 
sions, with opisthotonos lasting two to three minutes. Potassium 
bromide, drams ix; urotropine, gr. x; morph, sulph., gr. J. 

October 5. Potassium bromide, drams ivss, and urotropin, gr. 
v. Antitoxin, 10,000 units, subcutaneously. Morph, sulph., gr. 
I; intraspinal injection of mag. sulph., 25 per cent, solution, 6 c.c. 

October 6. Patient has developed pneumonia, and is in a critical 
condition. No convulsion since early morning. Antitoxin, 15,000 
units, subcutaneously. Potassium bromide, drams ijss; urotropin, 
gr. XV ; atropine, gr. mag. sulph., intraspinally, 3 c.c. of a 25 
per cent, solution; whisky, oz. iiiss; tincture of digitalis, minims 
xl, hypodermically, in 10-minim doses. 

October 7. Patient in very critical condition. Died at 6 p.m. 

Case 23. — Gregol S., aged twenty-eight years. Admitted, 
March 15, 1912. Discharged, April 20, 1912. Cured. Service 
of Dr. Neilson. Attending, Dr. John. 

Chief complaint is rigidity of jaw and neck muscles; wound of 
right foot. 

March 5. The patient ran a piece of a brass bolt into the outer 
side of his foot, and went to a “lodge doctor,” who bandaged it 
without any further treatment. Eight days later, on Wednesday, 
March 13, began to have pain and rigidity of muscles of jaw and 
neck. Was admitted on Friday night, March 15, with well-marked 
trismus and considerable rigidity and retraction of neck with 
moderate arching of the back. 

On Admission. Symptoms as above. Face is drawn, mouth 
particularly being drawn at the corners into the typical tetanic 
risus sardonicus. The head is rigid and well drawn back. Com- 
plains of some pain in the neck and thorax. ' Is able to separate 
the teeth about one inch. 

Thorax: Lungs negative. Heart area normal and sounds good. 
No murmurs. Back arched from occiput to buttocks, but the legs 
are freely movable. Centre of arch about three inches above the 
bed. 

Abdomen: Board-like rigidity of all the abdominal muscles, 
increased on examination. A small inguinal hernia on right side. 

Extremities: All are normal, with the exception of the right 
leg, which shows a penetrating wound on the outer side of the 
right foot about the middle of the arch. This runs up and back 
under the skin below the external malleolus for about three inches. 

IMarch 15. Wound in foot opened its whole length; slough cut 
away; washed with peroxide and warm boric, and packed with 
iodoform gauze; GOOD units tetanus antitoxin injected subcuta- 



116 ASIIHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 

neously. Chloral hydrate, gr. xx, and potassium bromide, gr. x, 
every four hours, with morph, sulph., gr. |, hypodermically, every 
four hours. 

March 16. 93,000 units of antitoxin injected subcutaneously. 
Patient is not so well. Can barely separate teeth, and has convul- 
sive spasms every few seconds. No real convulsion, however. 

March 17. 65,000 units of antitoxin injected subcutaneously. 
Patient can open mouth a little wider, but the convulsive spasms 
keep up, and there is more rigidity and arching of the back. 

March 18. 60,000 units of antitoxin injected subcutaneously. 
Patient in about the same condition. No worse. 

March 19. No antitoxin. Patient has had first real sleep this 
morning. Slept again for several hours in the afternoon. Convul- 
sive spasms are not quite so frequent, nor so severe. Arching and 
rigidity not diminished, possibly slightly increased. 

March 24. Patient is much improved, and rests quietl3L Bro- 
mide and chloral reduced by half. 

March 26. Patient rests quietljq but rigidity continues undi- 
minished, and considerable urticaria over body. Given soft-boiled 
egg and a small piece of dry toast for dinner. 

March 27. Rigidity considerably decreased, patient in good 
condition. 

March 30. Patient’s general condition is good. Rigidity is 
well marked but decreasing slowljq most marked in abdominal 
muscles. Blood pressure of left arm: sj'stolic, 182; diastolic, 124. 

March 31, Hot bath for fifteen minutes seemed to decrease 
rigidity to a considerable extent. Returned later in the daj'^, but 
the patient was much more comfortable. 

April 3. Transferred to convalescent Avard. 

April 7. Patient is doing well, and is up and in chair dailju 

April 16. Patient put on full diet. Is up and AA'^alldng about 
the ward. Is still a little Aveak, and is slightly sore in the chest, 
but on the whole is in good condition. 

April 20. Patient is up and about. Still has slight soreness 
over loAver thorax. Discharged in good condition. 

November 17. Returned for examination. No sj'^mptoms since 
recoverjq and in excellent health noAV. 


References. 

Almagia and Mendes. Internat. Clinics, Philadelphia, 1008, iii, 12. 
Bacelli. London Med. Mag., 1893-’94, ii, 811. 

Beates and Thomas. Monthly Cyclop, and Med. Bull., 1911, iv, 320. 
Blake. Surg., Gyn., and Obst., 1906, i, 541. 

Bockenheimer. Arch. f. klin. Chir., 1908, Ixxxvi, 277. 

Busch. Arch. f. klin. Chip., 1907, Ixxxii, 27. 

Camus. C. R. Soc. de Biol., Paris, 1912, Ixxii, 109. 

Dehne and Hamburger. Wien. klin. Woch,, 1904, xvii, 807. 

Donitz. Deutsnh. med. Woch., 1897, xxiii, 428. 



ASIIHURST, JOHN: THE RATIONAL TREATMENT OF TETANUS 117 

Fedden. Clin. Jour., 1911, xx.^vii, 3SG, Case 2. 

Fink. Jour, of Trop. Med., 1911, xiv, 161. 

Fox. New York Med. Rec., 1910, ii, 720. 

Frazier. Keen’s Surgery, Philadelphia, 1906, i, 478. 

Fricker. Deutsch. Zeit. f. Chir., 1907, Ixxxviii, 429. 

V. Graff. Mitth. a. d. Grenzgeb. d. Med. u. Chir., 1912, xxv, 145. 

Gumpreoht. Deutsch. med. Wooh., 1894, xx. 546. 

Gumpreoht. Arch. f. d. ges. Physiol., 1894, lix, 105. 

Hessert. Surg., Gyn., and Obst.. 1909, ix, 145. 

Hitchens. American Vet. Rev., August, 1910. 

Hofmann. Beitr. z. klin. Chir., 1907, Iv, 697. 

Huber. Beitr. z. klin. Chir., 1912, Ixxvii, 139. 

Hutchings. Surg., Gyn., and Obst., 1909, ii, 11. 

Imperiali. Giorn. di med. Milit., 1910, fase. x to xi: in Policlinico, 1911, xviii, 363. 

Jacob. Blumenthal and Jacob: Berl. klin. Woch., 1898, x.xxv, 1079. 

Jacobson and Pease. Trans. Amer. Surg. Assoc., 1906, xxiv, 254. 

Kintzing. New York Med. Jour., 1911, xi, 1268. 

Krauss and Amiradzibi. Zeit. f. Immunitiitsforsch., 1910, vii, 1. 

Kiister. Centr. f. Chir., 1905, xxxiii. Boil., S. 15. 

Lop. Bull. Soc. Chir., Paris, 1906, xxxii, 184. 

V. Leyden. Berl. klin. Woch., 1899, xxxvi, 632; Deut. mod. Woch., 1901, xxvii, 477. 

Luckett. Med. and Surg. Repts., Bellevue and Allied Hosps., New York, 1904, i, 319. 
Magula. Beitr. z. klin. Chir., 1911, Ixxvi, 588. 

Maunourj'. Assoc. Franc, de Chir., 1902, xv, 60S. 

Marie and Morax. Ann. de ITnst. Pasteur, 1902, xvi, SIS; 1903, xvii, 335. 

Matas. Trans. Amer. Surg. Assoc., 1909, xxvii, 40. 

McCampbell. Jour. Amer. Med. Assoc., 1907, i, 919. 

McFarland. Jour. Amer. Med. Assoc., 1903, ii, 34. 

Meyer and Ransom. Arch. f. exp. Pathol, u. Pharm., 1903, xlix, 369. 

Miller. Ameh. Joun. Med. Sci., 19C8, ii, 781. 

Neary. New York State Jour, of Med., 1910, x, 476. 

Nissen. Deutsch. med. Woch., 1891, xvii, 775. 

Nocard. Bull. Acad, de M6d., Paris, 1895, xxxiv, 407. 

Palmer. Jour. Royal Army Med. Corps, 1912, xviii, 400. 

Paterson. Lancet, 1910. i, 922. 

Porter and Richardson. Boston Mod. and Surg. Jour., 1909, cl.xi, 927. 

Pribram. Prag. med. Woch., 1908, xxxiii, 719. 

Remertz. Inaug. Dissert., Berlin, 1911. Ueber prophyl. Injcktion von Tetanus Antitoxin, 
Reynier. Bull. Acad, de M6d., Paris, 1908, lix, 623, 629, 780. 

Riche. Bull, et M5m. Soc. Chir., Paris, 1912, xxxxdii, 476. 

Rogers. Jour. Amer. Med. Assoc., 1905, ii, 12. 

Roux and Borrell. Ann. de I'lnst. Pasteur, 1898, xii, 225. 

Sawamura. Arboiten a. d. Inst. z. Erforschung d. Infektionskrankh. in Bern (Kollc), Heft iv, 
1, Jena, 1909. 

Schnitzler. Centr. f. Bakteriol., 1893, xiii, 679. 

Sewaki. Sei-i-Kwai Med. Jour., Tokyo, 1910, xxx, 33. 

Simon, v. Graff: Mitth. a. d. Grenzgeb. d. Med. u. Chir., 1912, xxv, 145. 

Solieri. Centr. f. Bakteriol., 1910, Iv, 141. 

Sutor. Arch. f. klin. Chir., 1905, Ixxv, 113. 

Stintzing. Munch, med. Woch., 1898, xlv, 1265. 

Stintzing. Mitth. a. d. Grenzgeb. d. Med. u. Chir., 1898, iii, 461. 

Tarozzi. Cited, by Solieri, q. v. 

Vaillard. Bull. Acad, de Mfid., Paris, 1908, lix, 569, 587. 

Vincent. Ann. de I'lnst. Pasteur, 1904, xviii, 748; Soc. de Biol, de Paris, in Gaz. des H6p 
1908, Ixxxi, 620, 668, 921. 

Zupnik. Deutsch. med. Woch., 1900, xx\d, 837. 



118 WILLSON: SCLEHOTIC INVOLVEMENT OF THE MITRAL VALVE 


ISOLATED SCLEROTIC INVOLVEMENT OF THE MITRAL 

VALVE. 

By Robert N. Willson, M.D., 

OF PIIILADELPniA. 


The frequency of occurrence of mitral-valve deformity and 
disease independent of and in the absence of other cardiac-valve 
implication, is one that has received attention only, as a rule, from 
the standpoint of vegetative endocarditis. It has been described 
customarily as rheumatic in origin, and at least in its acute forms 
has been regarded as a part of true bacterial rheumatic disease. 

Sclerotic thickening and deformity, causing insufficiency or 
stenosis, and oftentimes both anatomic effects, have received 
scant attention at the hands of students of the heart, and per- 
haps less than has been merited by their actual frequency and 
interest. Both in the wards of the Philadelphia Hospital and in the 
autopsy opportunities of private practice I have been impressed by 
the sclerotic nature of occasional mitral lesions, which I had been 
led by the historj^ of the case during life and its course while 
under mj^ observation, to regard as subacute recrudescences of 
a bacterial endocarditis of a vegetative type. Usually the physical 
signs have indicated mitral insufficiency or mitral stenosis, or both. 
Less frequently the indications have been those of purely aortic 
disease. Irrespective of the location my attention has been attracted 
by the sclerotic nature of the process and the necessity of inquiring 
whether I had erred in my understanding of its etiology. I confess 
that with each new instance, in spite of the association of tonsillitis, 
joint symptoms, or even pericardial inflammation, I have been 
forced to look away from acute rheumatism as a satisfactory 
explanation of the lesion, and to search for-a more likely immediate 
cause. 

In this brief study I will refer only to the sclerotic changes of 
the mitral valve that occur in the absence of apparent lesions of 
the other cardiac valves. In a later communication I hope to 
point out the significance of similar processes limited to the aortic 
valve. 

The Anatomical Lesion. I have already referred to the fact 
that I have at autopsies studied examples of sclerotic insufficiency, 
also of the frequent combination of sclerotic stenosis with insuffi- 
ciency of the mitral valve. I have never seen such a stenosis in 
the absence of an accompanying anatomical insufficiency, though 
not always of such a character as to furnish the classical ausculta- 
tory signs. I have observed a fibrosclerotic insufficiency in the 
absence of a deformity amounting to an anatomical stenosis, though 
far less regularly did the patient during life show either the physical 



WILLSON; SCLEROTIC INVOLATDMENT OP THE MITRAL A^ALVE 119 

signs or the symptoms of valvular obstructive disease. The pho- 
tographs are illustrative of the isolated sclerotic involvement of 
the mitral vavles. 



Fia. 1. — High-grade sclerotic involvement of the mitral valvo resulting in stenosis and 

insufficiency. 



1 


Fin. 2.— Sclcro.-=is and atheroma of the left auricular wall and of the mitral valve. 



120 WILLSON: SCLEROTIC INVOLVEMENT OF THE MITRAL VALVE 

Microscopic study of the diseased valve leaflets and cusps has 
shown in the early cases the typical changes of a fibrosclerosis. 
Ill more advanced cases atheromatous degeneration is often super- 
imposed, and in a large percentage, lime salts have been deposited, 
and resulted in a greater or less degree of calcareous change. 
There has been an entire absence of bacterial findings, and, as 
far as staining methods are concerned, there has been a complete 
failure to demonstrate the presence or the causal influence of 
bacterial forms. I shall later refer to the possibility of the demon- 
strating spirochetre in such tissue. The success of a number of 
laboratory workers in staining the Spirochaeta pallida in sections 
of the aorta that have been in preservative fluids for a number of 
years leads us to believe that we will yet be able to determine a 
causal organism in at least those instances that depend upon the 
Spirochieta pallida for an etiologic factor. All grades of fibrosis 
of the mitral valve have been observed from the slightest possible 
thickening to a gross deformity such as is seen in Fig. 2. 

The Physical Signs and Clinical Course of the Disease. 
I know no clinical method of distinguishing the sclerotic type of 
valvular disease from the vegetative except in the probable exclu- 
sion of syphilis from the etiology by the Wassermann test. In 
many of the cases that have come under my observation, syphilis 
has either been admitted by the patient, or there has been sufficient 
reason to believe that such an admission would be in order. I 
believe that many instances of hereditary lues are evidenced in 
childhood by fibrous arteries and by sclerotic involvement of the 
mjmcardium and of the valves — the mitral, the aortic, seldom 
both in the same case prior to late adult years, I reported 
several j'^ears ago a study of a child of four years dying of a 
rupture of an aortic aneurysm. The aortic valve was so com- 
pletely closed by sclerotic thickening and deformity as to cause 
wonder that enough blood could have passed its ring to maintain 
life. The child’s arteries were of the pipe-stem order. The mother 
was apparently healthy, but the father had a- slight degree of 
saddle-nose, and developed epileptiform convulsions at thirty-one 
years. He was in all likelihood a case of latent hereditary syphilis 
or a none too frank instance of the acquired type. 

In a few cases of this nature I have neither been able to obtain 
an admission from the patient that luetic infection has taken 
place, nor have I had any reason to think the statement of his 
freedom from infection was incorrect. I have seen cases that 
clinically resembled tonsillitis and rheumatism, with endocarditic 
involvement, which later at the autopsy showed an isolated sclerosis 
of the mitral valve. I remember one little girl that gave only a 
history of recurrent tonsillar swelling, yet whose arteries and 
mitral valve were as rigid as those of an old person. 

To the question. What is the exact nature of such a case, I 



WILLSON: SCLEROTIC INVOLVEMENT OF THE MITRAL ^^•\.IA'E 121 

reply, I do not yet know. Only a searching study^ of sections of 
the arteries and the valve leaflets of such cases will exclude the 
spirochete, and only the Wassermann test, ernployed as a routine 
measure in cardiac disease, will assist in the diagnosis in vim. 



Fig. 3. — Sclerosis of the mitral valve. Great hypertrophy of the left ventricular wall. 


These sclerotic changes occur in the absence of the classical signs 
of acquired syphilis. Syphilis not infrequently causes a symptom- 
complex indistinguishable (except by laboratory means) from 
that of both acute inflammatory rheumatism and of tonsillitis, 
and it can and does leave in some instances permanent traces in 
the form of thickening and deformed mitral leaflets. Whether 
it is the usual cause of these isolated scleroses is another matter. 
I have also noted two instances of sclerotic involvement of the 
mitral valve in sisters, members of a family in which a large number 
of the recent ancestry had been tuberculous. One parent, the 
mother, had died in early life, probably though not certainly of 
tuberculosis. The father died of a systemic nervous disease that 
may easily have been luetic in origin. The children of this paren- 
tage, five in number, have all shown evidence of cardiac valvular 
disease, which in at least two instances was limited to the mitral 



122 WILLSON: SCLEROTIC INVOLVEMENT OF THE MITRAL ALILI^E 


valve. Thus we have the possibility of a tuberculous influence 
and the certainty that syphilis may and sometimes does produce 
such a picture alone. 

Whether other infections may constitute or independently 
cause isolated valvular sclerosis can only be determined by the 
studies of many observers of a large series of cases. Dr. James M. 
Anders informs me that he has studied two interesting cases of 
this type of mitral involvement in which the causative factor 
remained unknown. Whether or not acute infectious rheumatism 
can and ever does cause sclerosis of the valvular tissues is also a 
point to be considered. As a rule, fibrosis does not form even a 
prominent feature of the damage consequent upon this disease. 
Vegetative endocarditis is so generally a rheumatic sequela that this 
type of valvular disease may almost be regarded as rheumatism 
of the endocardium. We may therefore pass it over as an unim- 
portant factor in the etiology of the conditioji under consideration. 
The text-books have seemingly overlooked mitral sclerosis and 
implication of the bicuspid valve. 


Fig. 4. — Fibrosis of the mitral valve. Marked dilatation of the left ventricle and relative 
mitral insufficiency. Great hypertrophy of the papillary muscles. 

Possibility of Antemortem Diagnosis. From my experience 
in the cases studied by me I am inclined to believe that all patients, 
irrespective of age, with sclerosis of the mitral valve, whetlier 
associated with other valvular involvements or isolated, will be 
found also to present sclerotic arteries. The child of four years 





WILLSON; SCLEROTIC INVOLVEMENT OF THE MITRAL VALVE 123 

already mentioned as dying from a ruptured aortic aneurysm had 
brachial and radial arteries that would have done credit to an intem- 
perate old man. This early arteriofibrosis, together with a prema- 
ture overaccentuation of the second aortic sound and a tendency to 
hypertrophy of the left ventricle, will in the presence of the signs 
of developing mitral disease afford reason to anticipate fibrosis 
rather than a deposit of lymph and bacteria as the condition of 
affairs likely to be revealed at the autopsy. A definite history of 
syphilis or tuberculosis in the patient or in his or her parents will 
go far toward rendering presumptive evidence certain. 

Preventive Measures and Treatment. The only certain 
preventive measure would be prevention of marriage among the 
unfit. The question of the right to marry among those who are 
morally certain to transmit stigmata, if not actual disease, is not 
a proper subject for a strictly clinical discussion. It has its bearing, 
however, immediately we begin to consider the prophylaxis of 
valvular disease. 

I doubt whether in the presence of sclerotic arteries in child or 
adult much can be done in the way of forestalling sclerotic heart 
change. Both the cardiac muscle and the valve leaflets seem 
destined to proceed in the course which they have begun before 
the presence of a toxic factor has been recognized. It is probably 
too late for us to expect much valvular benefit from antiluetic 
medication, though in the presence of repeatedly positive Wasser- 
mann reactions, thorough courses of arsenic and mercury should be 
instituted. The studies of Finger and other reliable investigators 
would seem to indicate that hereditary syphilis is an incurable dis- 
ease. In the absence of such symptoms as those of lues, we are 
peculiarly helpless against the insidious march of an irremediable 
affection. The treatment therefore again reverts in the present 
very imperfect state of our knoAvIedge of the etiology of these con- 
ditions to a new interest in human eugenics, and to precautionary 
breeding measures that will prove as intelligent in the reproduction 
of the human species as in the raising of healthy cattle, horses, and 
hogs. • 



REVIEWS 


Progressive Medicine. A Quarterly Digest of Advances, 
Discoveries and Improvements in the Medical and Surgical 
Sciences. Edited by Hobart Amory Hare, Professor of 
Therapeutics and Diagnosis in the Jefferson Medical College 
of Philadelphia; Physician to the Jefferson Medical College 
Hospital; assisted by Leighton F. Appleman, M.D., Instructor 
in Therapeutics, Jefferson Medical College, Philadelphia, etc. 
Vol. I, March, 1913; pp. 353. Philadelphia and New York: 
Lea & Febiger. 

The first volume of Progressive Medicine for this year opens 
with an article of 106 pages on the surgery of the head, neck, and 
thorax by Charles H. Frazier, The hypophysis, meningitis, and 
trigeminal neuralgia are among the most important subjects con- 
sidered under the head. A Avealth of interesting material is 
revieived in the course of his discussion of the thorax, particularly 
surgery of the heart and great vessels, intratracheal insufflation, and 
.surgerj^ of chronic disease of the lungs. The most noteworthy 
topics discussed in the remainder of his contribution are cancer 
of the mouth, lips, tongue, and pharynx, cervical lymphadenitis, 
cervical ribs, goitre, and breast tumors. 

John Ruhrah has contributed a most interesting article of 112 
pages on infectious diseases. He lays particular stress upon cerebro- 
spinal fever, diphtheria, kala-azar, leprosy, pneumonia, polio- 
myelitis, scarlet fever, tetanus, typhoid fever, tuberculosis, and 
pertussis. No one can read 'this summary without being impressed 
by the notable advances that are being made in this branch of 
medicine. 

Diseases of children are considered by Floyd M. Crandall in a 
short article. After dwelling upon infant mortality and child 
welfare, he takes up among other subjects, hemorrhage in the 
newborn, edema in infailts, chorea, achondroplasia, the exudative 
diathesis, and infant foods. 

Rhinology and laryngology are ably discussed by George B. 
Wood. He first revieAvs the question of the choice of anesthetics 
for nose and throat operations; then among other interesting topics, 
he considers submucous resection of the nasal septum, nasal diph- 
theria, various forms of rhinitis and accessory sinus disease; septic 



DEAVER: APrENDICITIS 


126 


sore throat and Vincent’s angina are among the subjects taken 
up under tlie pharynx. He then discusses the tonsils and their 
surgery, and finally devotes considerable attention to the larjmx. 

A contribution on otology, by A. B. Duel* completes the volume. 
He fully enters into the subjects of meningitis, the labyrinth, the 
treatment of specific disease of the ear with salvarsan, otosclerosis, 
and neoplasms of the ear. 

The volume is one of decided value and the authors are to be 
commended for their careful selection of so many subjects of great 
present-day interest. G. hi. P. 


Appendicitis. By John B. Deaver, M.D., Sc.D., LL.D., Pro- 
fessor of the Practice of Surgery, University of Pennsylvania. 

Fourth edition; pp. 379; 14 illustrations. Philadelphia: P. 

Blakiston’s Son & Co., 1913. 

Seventeen years ago the first edition of this book was criticised 
— on the whole unfavorably — ^by the present writer. The specific 
counts of the indictment against the book were chiefly as follows: 
(a) A lack of information as to the proportion of recoveries from 
genuine attacks, without operation; as to the number of such cases 
who have second attacks; as to the proportionate fatality of such 
recurrences as compared with primary outbreaks; as to the relative 
advantages of immediate operation and of delay in cases seen 
some days after the primary seizure, and which show signs of 
the formation of a localized abscess; as to the existence or non- 
existence of “stercoral typhlitis,” and of the “simple catarrhal” 
or “mechanical” forms of appendicitis, those thought to be caused 
by a stretching or a twisting of the meso-appendix; (b) insufficient 
description of the relapsing and recurrent forms of the disease and 
of its complications; (c) a too free use of other authors without 
adequate acknowledgment; and (d) a too absolute insistence upon 
the rule that “where practicable all cases of appendicitis should 
be operated upon as soon as the diagnosis has been established,” 
though as to the last point, the reviewer added; “This may be 
good surgery; time will show.” 

It has been most interesting to read the present edition of this 
book with these criticisms of nearly two* decades ago in mind. 
It is fair to say: 

First, that such retrospective comparison demonstrates that, as 
has been the case with many reviewers, from the daj-s of “The 
Dunciad or of ‘ English Bards and Scotch Reviewers” down to 
this relatively insignificant instance, it is apparent that it is easier 
for a reviewer to be, or to seem, clever than to be just. There 

VOL. 14G, NO. 1. — JULY, 1913 5 



126 


REVIEWS 


were faults to be condemned, of course, but there were also excel- 
lences to be commended, and it is now apparent that the latter 
were not given their proper proportionate prominence. 

Second, whatever may have been the genuine faults of the 
edition of 1896, they have in the changes and additions of the 
intervening years practically disappeared from the edition of 
1913. 

The experience and the resulting statistics, not only of the 
author, but of the whole profession, have so vastly broadened 
during this period that questions which were then pressing for 
solution are no longer debatable, and analytieal studies of series 
of individual cases, then much to be desired would now be a waste 
of time and effort. 

The increased experience of the author is shown in the fact 
that whereas the first edition -was based on a “series -of 500 cases” 
his present views have back of them “an experience involving 
about 10,000 cases of appendicitis” (p. 224). 

As to the supposed individual faults of the early edition, we 
now find by contrast a thorough and entirely satisfactory descrip- 
tion of all the varieties of appendicitis and of its complications, 
clear and succinct, but comprehensive. 

Familiarity with the literature of the subject is shown, but 
the fullest possible credit is given where credit is due. The teachings 
as to operation are no less positive, but, as to this, it should cer- 
tainly be- admitted that the surgeon who has seen 10,000 cases 
of a particular condition has at least twenty times the right to 
be uncompromising or even dogmatic in his advice to practitioners 
and students that he had Avhen he had seen only 500 cases. In 
reality, his right to be positive increases far more than by that 
simple arithemtical proportion. It is certain that when, as in 
these instances, he speaks clearly and unequivocally, and bases 
his teachings not only on his own experience, but on well-sustained 
and Avell-defined clinical and pathological theories, the professional 
world must listen respectfully. 

Some specific comparisons vdth the earliest edition may be made 
with adAmntage. 

The section on Differential Diagnosis contains more than twice 
the number of words and a vastly more useful comparison of the 
various conditions that may be confused with appendicitis. Clinical 
Etiology is similarly enlarged and improved. The section on 
Pathology, increased more than four-fold, is a masterly exposition 
of our knowledge of this underlying subject. The summaries of 
the Principles of Symptomatology (p. 195) and of Diagnosis 
(p. 216), the Recapitulation of the Pathological Factors (p. 170), 
the discussion of the Medical Treatment of Appendicitis (p. 355), 
may be singled out for approval as special examples of the admirable 
handling of the subject that characterizes the book as a whole. 



deaver: appendicitis 


127 


Particular mention should also be made of the section on Peri- 
tonitis, which is exceedingly interesting and instructive. INIost 
surgeons of today will agree w^itli the author ■when he states (p. 32) 
that saline enteroc^^sis by Murphy’s continuous method is the 
greatest advance in the postoperative treatment of abdominal 
conditions in the last decade. He says that by its use he has been 
able to reduce his mortality in cases of diffuse peritonitis to less 
than 2 per cent. — a truly noteworthy showdng. 

The most radical change of opinion the revieiver has noticed 
relates to the early administration of laxatives, and it is instruc- 
tive to note that in 1896 that was a question as to -which he and 
the author rvere in absolute accord. 

In the first edition. Dr. Deaver said: “I am perfectly familiar 
wdth the unfavorable opinions of a number of other writers upon 
the advisability of the administration of laxatives in appendicitis, 
but my experience has taught me that it forms the onl^’- successful, 
and therefore justifiable, treatment -udien operation cannot be 
performed. I do not hesitate, therefore, to offer it to my readers 
as sound and rational therapeutics. I repeat that laxatives should 
be given early, and in sufficient quantity to produce thorough 
evacuation of the bo-n^el, for they accomplish the most good ivhen 
given thus. . . . The benefit of unloading the bowel far 

outweighs the danger of breaking up any adhesions that may 
be forming.” 

In the present edition he says: “The most important points 
to be observed in the suspected presence of acute appendicitis 
are negative rather than positive, and consist in the prohibition 
of everything by mouth, including water, and especially the 
avoidance of all purgative medicine.” 

He also prohibits anodynes, and at present the only difference 
in our respective views -would be that at the end of the above- 
quoted sentence w^e -would say “especially the avoidance of all 
anodynes,” leaving to purgatives a secondary place as to possible 
harmfulness. At any rate, this example sho-^vs what is apparent 
throughout the book, that the author has the courage of his con- 
victions and is still young enough to change his mind. 

We have noticed but feiv typographical or other errors. On 
page 40 the reference to the period wdien prompt “ablation of the 
diseased organ meant cure without hope of relapse” should prob- 
ably read “fear of relapse.” The latter -n^as scarcely to be “ hoped” 
for by any one. On page 217, the statement that fever is “next to 
never” the first symptom, sounds a trifle colloquial. On the same 
page we would prefer to see “excrutiating” spelled “excruciating,” 
though in these days of changing orthography, that is of slight, 
importance. On page 357, “Purgatives . . . hastens,” .should, 
of course, take the singular form of tlie verb. But the proof- 
reading in the main has been well done and the 'udiole book is 



128 


REVIEWS 


creditable as to its style and manner as well as to its teachings. 
Indeed, as to the latter, it is not over-praise to say that it is at 
once the most clear and compact and the most authoritative 
presentation of its important subjeet that is today before the 
medical profession. J. W. W. 


Augustus Charles Bernays. A Memoir. By Thekla Bernays. 

Pp. 309. St. Louis; C. V. Alosby Company, 1912. 

This memoir of the late Dr. Bernays written, by his devoted 
sister, constant companion, and chief confidant, has been read 
with a great deal of interest by the reviewer. The early life of the 
subject of these pages, treated in the first six chapters, of which 
chapters there is a brilliant interlude by Prof. Furbinger, were 
read with the most pleasure. Thej'- seemed to be, in a sense, an 
extremely intimate and therefore affectionate portrayal of the 
early days of any man, wherein the vagaries of youth and the 
budding of maturity are all set forth in a way that reminds us 
of certain pages of “Jean Christophe.” We were perplexed to 
discover what might be the motive of the authoress in offering 
to the public and to the cold gaze of the reviewer, this seene of 
family vdth its manners, trials, successes, affections and love, for 
sueh things are generally beheld only by a favored few. This 
perplexity was unfortunately increased by our laek of familiarity 
vdth the work, achievements, or even name of Augustus Charles 
Bernays. The bibliography appended to the memoir shows the 
■wide scope of his medical writings, and but added to the chagrin 
of the re^'iewer in being so lamentably unfamiliar with “one of 
the most brilliant surgeons that this country has ever produced,” 
to quote from the publisher’s letter. 

We do not wish to hurt the feelings of a sister who ean so 
lovingly and appealingly record the virtues of an adored brother, 
and who can so tenderly and with sueh a gentle way of offering 
excuse for what she indeed thinks to be the opposite, pen his 
peccadillos. Miss Bernays’ quaint remark on things medical, 
her naive comparison between gastrostomy and appendectomy, 
and her ingenuous chapter on Dr. Bernays’ Views on Fever, where- 
in, unconsciously, she sets forth her own at great length, all these 
add to the charm if not to the value of the volume. We have 
gathered the impression, we who have perused carefully, calmly, 
and dispassionately these memoirs, that they are to be considered 
as a protest against what the authoress .regards as harsh treatment 
by the medical profession of her brother during his life. The reviewer 
being unfamiliar with Dr. Bernays’ medical activities in St. Louis 
cannot judge of this treatment, but he believes Be mortuis nil 



iiertzler: surgical operations with local anesthesia 129 

nisi bomivi. Perhaps the friends, enemies, colleagues, and students 
of Dr. Bernays will find the book of interest, but to the general 
medical public it cannot make a lasting appeal unless it does so 
as the literary product of a mourning sister still crying as she 
does in her pages, “Never was there another such a brother.” 

E. H. G. 


The Pathology of the Living, and Other Essays. By B. G. A. 
MoYNimvN, M.S. (London), F.R.C.S., Honorary Surgeon to 
Leeds General Infirmary; Professor of Clinical Surgery at the 
University of Leeds, England. Pp. 260. Philadelphia and 
London; W. B. Saunders Company. 

This little volume consists of nine now familiar essays by 
one of the most noted abdoniinal surgeons of the world, and 
should prove a welcome addition to many a medical library. 
The essays were for the most part originally delivered as ad- 
dresses before various medical societies, and although dealing 
with surgical subjects, are of no less interest to the general practi- 
tioner than to the surgeon. On the contrary, it is to the general 
practitioner that they should be recommended particularly, for it 
is safe to say that if the lessons taught in the essay on Pathology 
of the Living were firmly fixed in the minds of more general prac- 
titioners, more gastric carcinomas would come to the operating 
table at a period when they are operable, and fewer cases of gastric 
ulcer would be treated for months as chronic indigestion. 

The essays which comprise this book are so well known to the 
profession at large that they require no detailed comment. It is 
interesting to note, however, that many of the statements made 
for the first time_ by Moynihan in these addresses, all of which 
were delivered prior to the latter part of 1908, have been amply 
confirmed by the subsequent investigations not only of Moynihan, 
but also of a large group of abdominal surgeons in both Europe 
and America. G. M. P. 


Surgical Operations with Local Anesthesia. By Arthur 
E. Hertzler, M.D., Surgeon to the Halstead Hospital and 
to the Swedish Hospital, Kansas City. Pp. 205; 104 illustrations. 
New York: Surgery Publishing Co., 1912. 


This Avork has been undertaken to supply a demand for a sys- 
tematic, concise deseription of the uses and possibilities of local 
anesthesia. The author has made it a one-man book injthat he 



130 


REVIEWS 


gives merely his own technique and ideas. He describes only 
those operations which he thinks are applicable to local anesthesia. 

In discussing the advantages of local over general anesthesia 
he fails to appreciate the advantages of nitrous oxide and oxygen 
as a general anesthetic. 

The technique is described in minute detail, even including 
sterilization of skin and the demeanor of the operator. Of the 
various drugs employed the quinine urea solution is rightly regarded 
the safest. Cocaine is advised for the -operations demanding only 
small amounts of the anesthetic. Novocaine and eucaine are 
much favored because of their non-toxicity. 

The remaining thirteen of the seventeen chapters are concerned 
with the description of various operations. Each operation is 
described fully and individually. The anatomy, neural especiallj^ 
is outlined, the drugs, amounts used, and technique described 
step by step in detail. Thus the operator can read up his entire 
procedure in the one work. 

The style and diction of the work are good and make pleasant 
reading. However, the book has been poorlj' edited, as typo- 
graphical errors are noticeable, sueh as misspelled words and the 
transposition of parts of sentences. 

The illustrations fall short of accuracy in one or two particulars, 
and consequently would tend to confuse rather than aid the 
reader. 

However, the work is an instructive one in many respects, and 
one that every surgeon should have at his command. 

E. L. E. 


On the Physiology of the Semicircular Canals and Their 
Relation to Sea Sicpcness. By Joseph Byrne, A.M., M.D., 
LL.B. Pp. 569. New York; J. I. Dougherty, 1912. 

As stated in the preface to this volume, its author undertook 
to write an article on the etiology of seasickness some years ago, 
but “not satisfied with a mere expression of his view without 
appeal to experimental fact, and believing that the semicircular 
canals were in some way involved in the causation of the malady, 
he undertook a series of experiments, using rotations, aural irriga- 
tions, stimulation of the retina by strong light, galvanism applied 
to the mastoid areas, etc., to determine whether by such means 
phenomena resembling those of seasickness could be experimentally 
reproduced.” 

The text of this elaborate work is divided into three sections: 
(1) General anatomical and physiological considerations; (II) 
physiology of the semicircular canals; (III) seasickness. Pp. 339 
to 525. 



DENSLOW: THE SURGICAL TREATMENT OF LOCOMOTOR ATAXIA 131 

We may dismiss the first part without other comment than it 
is fully lucid and up to date. 

The second part, physiology of the semicircular canals, com- 
mences with a summary of the most authoritative results of experi- 
mentation on animals, and then details a long series of personal 
experiments upon human subjects, the results of which are minutely 
described, as they were manifested in organs near and remote from 
the aural structures. Numbers of these are tabulated in series 
of elaborate protocols, any summary of which here would be too 
superficial for usefulness. 

The third part is an equally elaborate experimental study of 
seasickness and its results on board ship. The general conclusions 
convinced the author that the effects of real seasickness are quite 
analogous to the artificial sickness caused by rotation, aural irriga- 
tions, and by galvanism applied over the mastoid areas. 

While all this work is learned, laborious, and interesting, it is 
doubtful whether this physical cause of seasickness is the real 
one. 

To conclude, the treatment suggested for seasickness is quite 
indeterminate and unsatisfactory. 

In maritime circles, however, seasickness of landsmen is often 
immediately cured by the psychic effects of a rope’s end or a knock- 
down blow with the fist. J. S. C. 


The Surgical Treatment op Locomotor Ataxia. By L. N. 

Denslow, j\I.D., Late Professor Genito-urinary Surgery and 

Venereal Diseases, St. Paul Medical College, Minnesota. Pp. 

118. London: Bailliere, Tindall & Cox, 1912. 

The purpose of this small volume is to present a new theory 
as to the cause of locomotor ataxia and a new method of treat- 
ment based upon this theory. The theory is as follows: “The 
dystrophic changes that occur in the neurons of the posterior 
roots and their connections in tabes are the result of continuous 
sensory impulses conveyed from some peripheral point to the 
sensory roots in the cord; that such continuous impulses, kept 
up, perhaps, for years, exhaust the central nerve substance which 
having no rest or intermission from such impulses, and having 
no opportunity for recuperation, finally succumbs.” The “peri- 
pheral point’] from which the “sensory impulses” originate, in 
the great majority of cases, is an inflamed or constricted portion 
of the urethra. About half of the book is given up to a discussion 
of the theory and the other half to a citatioia of cases treated by 
the author. The results obtained are at least suggestive but are 
not conclusive. ^ The greatest need in connection with the theory 
and treatment is confirmation bj' other workers in this field. 

T. T. T. 



132 


REVIEWS 


Handbook of Mental Exaimination Methods. By Shepherd 
Ivory Franz, Ph.D., Scientific Director and Psj^chologist, 
Government Hospital for the Insane; Professor of Physiology, 
George Washington University. Pp. 165; 33 illustrations. 
New York: The Journal of Nervous and Mental Disease Pub- 
lishing Co., 1912. 

This small book is one of the Monograph Series published by 
the Journal of Nervous and Menial Disease. The journal deserves 
a deal of credit for the excellence of its selection, for the series 
includes translations of such works as those of Sigmund Freud, 
Plant, Jung, and others. 

The present volume, which is No. 10 of the series, is a manual 
of the modern methods of examination of mental diseases. It is 
excellently done, and is a safe guide for tliose who intend to study 
psychiatry along modern scientific methods. T. H. AV. 


The Therapy of Syphilis. By Paul Mulzer, M.D., of Berlin. 

Translated by A. Newbold. 

The Therapy of Syphilis, by Dr. Paul Mulzer, consists of a 
brief essay of 44 pages on the mercurial and the more important 
arsenical forms of antisyphilitic treatment, other than salvarsan, 
with a history of their development, shortcomings, and discard; 
and a rather lenghty treatise of 160 pages on the therapy of syphilis 
by the Erhlich-Hata arsenical preparation, dioxydiamidoarseno- 
benzol or “606.” 

Mulzer gives a short history of the discovery of “606,” and 
animal experimentation by Ehrlich and Hata, a description of 
the various methods of preparation of the drug for the different 
forms of injection, and clinical conclusions on the value, contra- 
indications, criticisms, and results of its use, based on one year’s 
observations (January, 1910 to December, 1910), of many well- 
known European authorities. 

The rapid progress in our knowldege of the handling of this 
drug, both in the technique of its administration and the clinical 
discretion in its use, since December 1910, which Mulzer must have 
foreseen, reflects only credit to his industry in the production of 
such a work. 

This book should be, at least, of historic value and interest to 
the profession. J. L. L. 



PEOGKESS 


OF 

MEDICAL SCIENCE 


MEDICINE 


UNDER THE CHARGE OF 

W. S. THAYER, M.D., 

PEOFESSOR OF CLINICv\L MEDICINE, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYI,AND, 

AND 

ROGER S. MORRIS, M.D., 

CHIEF OF THE DEPARTMENT OF INTERNAL MEDICINE, CLIFTON SPRINGS SANATORIUM AND 
HOSPITAL, CLIFTON SPRINGS, NEW YORK. 


Alimentary Galactosuria in Experimental Phosphorus Poisoning. — 
R. Roubitsciiek {Deiitscli. Archiv f. klin. Med., 1912, cviii, 225), at 
the suggestion of Reiss, has studied the galactose tolerance of dogs 
during phosphorus poisoning. He found that galactosuria occurred 
with the acute degenerative changes produced in the liver cells. This 
fact, taken with the results of the studies of Reiss and Jehn, leads 
Roubitsciiek to believe that it is only the acute conditions which injure 
the liver parenchyma diffusely that interfere with the power of the 
organ to sjTithesize galactose to glycogen. In chronic conditions 
.such as cirrhosis, chronic passive congestion, etc., there is regeneration 
of liver cells which may compensate functionally to a sufficient degree 
to prevent the occurrence of galactosuria. 


The Bradycardia of Lead Colic. — ^It is not uncommon to observe, 
in the course of lead colic, an outspoken bradycardia. Tanquerel, 
in an analysis of 1179 cases, has found a pulse of 20 to GO in 678 in- 
stances, 65 to 70 in 376, and SO to 100 in 125. Lion and IMarcorelles 
(La Presse Med., 1913, Nr. 12, 109) have applied graphic methods 
and the atropine test to 4 cases. The tracings proved the condition 
a true bradycardia, with a normal phlebogram and no auriculoventri- 
cular disassociation. Each ventricular systole was preceded by a 
single auricular systole. The heart was normal but slow. Arterial 
hypertension and the bradycardia were independent. Both are prob- 
ably manifestations of saturnine intoxication. In each case, atropine 
jH'oduced a taehycardia, the pulse changing from 46 to 52 to 75 to 120. 
This leads them to conclude the toxic impregn.ation is either of the 
vagus trunk, or the nerve endings in the node of Keith and Elack. 



134 


PROGRESS OP MEDICAL SCIENCE 


Acetone and Diacetic Acid. — ^Bonnamour and Joubert {La Prcssc 
Med:, 1913, Nr. 14, 130) have modified the Legal and Gerhardt test 
for acetone bodies in the urine. They emphasize that the two are 
distinct, the first indicating the presence onlj’- of acetone, the second 
diacetic acid. The Legal reagent as modified was made with 10 grams 
of glacial acetic acid and 10 c.c. of 10 per cent, sodium nitroprusside. 
In a colored bottle, this can be kept several months. To 15 c.c. of 
filtered urine are added 20 drops of reagent. After mixture, ammonia 
is floated upon the surface drop by drop. The presence of acetone 
even in dilution of 1 to 2000 causes a violet disk at the line of separa- 
tion of the two. With the test acetone was detected in the urine of 
numerous non-diabetic patients. They concluded that acetonuria 
may be the index of acidosis, but in itself is not an indication of immi- 
nent diabetic coma. It is not evidence of the presence of diacetic 
acid. Gerhardt’s test for diacetic acid was performed by adding to 
urine diluted with four volumes of water a 10 per cent, solution of 
perchloride of iron drop by drop. Normal urine, containing even 
acetone, gives a white cloud. In urine with a trace of diacetic acid, 
the precipitate is a definite black violet cloud. The reaction is much 
more delicate than the original Gerhardt test, and is given only b}" 
diacetic acid. The two reactions are distinct for each acetone body. 

Syphilitic Aortitis. — Longcope (Arc/i. hit. Med., 1913, xi, 15) has 
observed no deflnite beneficial effect from salvarsan in 20 cases of 
syphilitic aortitis. Neither the cardiac competency nor the anatomical 
condition have been changed. Signs of aortic insufficiency have not 
been reduced and aneurysms have not grown smaller.' The most 
striking result has been upon the pain and attacks of paroxysmal 
dyspnea. The relief has been immediate and tends to be permanent. 
The persistence of a positive Wassermann reaction or the rapid return 
of a positive reaction after a temporary abatement during treatment 
have impressed the author. The improvement in symptoms manifests 
itself very rapidly, usually within four to six days, but this is associated 
■with an increase in the se'v'erity of symptoms witliin twenty-four hours 
to forty-eight hours after the intravenous injection. This is particularly 
true of angina pectoris and paroxysmal dyspnea. The rapid ameliora- 
tion of the pains, attacks of angina pectoris, and paroxysmal dyspnea 
suggests certain explanations for these s;^Tnptoms. Autopsies have 
not been con^’incing of any direct association between diseases of the 
coronary arteries and these attacks. The suggestion is strong that the 
symptoms are associated with the inflammatory reaction at the root 
of the aorta and directly dependent upon it. The increase in the 
severity of symptoms after injection resembles a Herxlieimer reaction, 
the increase in symptoms due to increased reaction of the tissues 
toward the liberation of toxins in excess from rapidly destroj^ed spiro- 
chetes. The dyspnea caused by bronchospasm, and the contraction 
of the peripheral arteries producing heightened blood pressure from 
aortic irritation in experimental animals is a .close reproduction of 
the paroxj’^smal dyspnea, as it occurs in syphilitic aortitis. Longcope 
beheves these symptoms dependent upon a reflex generated at the 
root of the aorta by the syphilitic inflammatory process. At any 
rate, the true etiology probably lies in the diseased aorta, and this 



MEDICINE 


135 


is supported by the Herxheimer reaction, combined with the rapid 
improvement and later recurrences. Longcope in conclusion considers 
that syphilis produces a characteristic lesion of the aorta which is 
responsible for most aneurysms, about 7_5 per cent, of cases of aortic 
insufficiency in adults, many cases of dilatation of the aorta, and a 
certain group of cases of angina pectoris. The infection of the aorta 
probably taken place during the secondary stage, and the process 
usually remains latent, or unrecognized for an average of sixteen or 
seventeen years. Thus syphilitic aortitis is probably a common cause 
for a positive Wassermann reaction in so-called latent syphilis. 

Congenital Family Steatorrhea.— Gakrod and Hubtley (Qiiarterly 
Jour. Med., 1913, vi, 242) report tlie case of a boj’-, aged eight years, 
subject from infancy to true steatorrhea, the passage from the bowel 
of liquid fat which solidifies on cooling. His parents are first cousins. 
A brother was similarly affected from birth. The boy is well nourished 
and exhibits no other morbid conditions. There are no signs of pan- 
creatic disease besides the steatorrhea. On a diet containing very 
little fat his stools assume a normal appearance and consistency. 
Analyses show he excretes in his stools 25 per cent, of the fat taken by 
mouth. Improved saponification is not followed by improved absorp- 
tion. The boy is presumably the subject of a rare inborn error of fat 
absorption, probably a Mendelian recessive characteristic. Investiga- 
tion did not reveal where the error lay. 


On Uric Acid Excretion in Hypophyseal Disease. — W. Falta and 
J. Nowaczynski {Berlin. Jclin. Woch., 1912, xl, 1781) find no data on 
uric acid excretion in hypophyseal disease. Their own findings on a 
limited material are of considerable interest. The patients were placed 
on a purin-free diet, and the uric acid of the urine was determined by 
the method of Hopkins-Folin-Shaffer. In 3 cases of acromegal}'- they 
found the endogenous uric acid to be twice the normal average or 
greater. ' In 1 patient there was an endonasal resection of part of the 
hypophysis. No clinical evidence of improvement was noted shortly 
after the operation, nor was there any decrease of the uric acid output, 
compared with the pre-operative periods. In this patient there was a 
prompt increase in uric acid following the administration of 20 grams 
of sodium nucleinate. In 2 cases of dystrophia adiposogenitalis asso- 
ciated with hypophyseal tumor (one hypophysis cystic at autopsy, 
the other “a tumor in the hypophysis region”), they found, on the 
other hand, that the endogenous uric acid was normal or subnormal, 
^ with only a slight response to the administration of sodium nucleinate. 
They_ assume that the acromegalics are suffering from an increased 
functional activity of the hypophysis, and on this basis they suggest 
that^ the determination of endogenous uric acid may be of some diag- 
nostic value, provided their results are borne out by the study of a 
larger material. 


Autoserotherapy and Absorption of Ascites.—ViTRY and Sezary 
de Medecine, 1913, xxxiii, 86) studied the absorption of ascitic 
fluid m a case of cirrhosis of the liver. The patient, a woman, aged 
hity-two years, had noticed the insidious swelling of the abdomen 



136 


PROGRESS OF MEDICAL SCIENCE 


for six months. The abdomen was bulging with a large ascites, esti- 
mated at 8 . to 10 liters. There was a prominent collateral circulation. 
The cause of the hepatic lesion was obscure, probably alcoholic. On 
a milk diet, the urinary output was 1000 to 1400 c.c. Subcutaneous 
injections of ascitic fluid were given; 10 c.c. were injected in the abdom- 
inal wall immediately after withdrawal. This was done every two 
days. On the third day an abundant diuresis began and increased 
to the point when eleven days later the therapy could not be continued 
for lack of ascitic fluid. The body weight diminished in a corresponding 
way. An increased chloride content coincided with the polyuria and 
loss of weight. The acidity of the urine Avas diminished by the elimina- 
tion of the alkaline ascitic fluid. The authors were impressed with the 
favorable influence, although they claimed no effect upon the condi- 
tion of the liver. However, the disappearance of evidence of portal 
obstruction was maintained, CA'^en Avhen the patient returned to a salt- 
containing diet. 


On the Presence of Typhoid Bacilli in the Mouth of Typhoid Fever 
Patients and Typhoid Convalescents. — B. Purjesz and 0. Perl 
(Wien. /dm. Woc/i., 1912, xxv, 1494) have made cultures from the 
gums, tonsils, and tongue of patients suffering with typhoid fever. 
Sterile swabs AA^ere rubbed on the mucosa, and then, tubes containing 
Conradi-Drigalski medium were inoculated. The organisms Avere 
finally identified by agglutination tests AAUth the serum of a rabbit 
inoculated Avith typhoid bacilli, whose serum agglutinated in a dilu- 
tion of 1 to 3000 in tAAxnty minutes. They examined 17 cases in all. 
In about 50 per cent, of the cases a posith’^e result was obtained. Dur- 
ing the febrile period a positiA’-e culture was obtained as late as the 
tA\’’entieth day. The authors haA’^e obtained the organisms from the 
mouth as late as the fourth to eighth A\'eek of convalescence, confirm- 
ing the obserA'ations of Gould and Quales, Avhich appeared during the 
course of the authors’ study. The findings are important both from 
the standpoint of diagnosis and epidemiology. 


Blood Findings in Adiposity. — Caro (Berlin, /din. Woch., 1912, 
xl, 1881) has made counts and histological studies of the blood in 
34 patients suffering AA'ith adiposity. There were 19 cases of “consti- 
tutional” adipositj^ 6 cases folIoAA'ing the climacteric, and 9 cases 
of “alimentary” adiposity. The blood showed constantly a lympho- 
cytosis, as high as 62 per cent., AA'ith a decreased percentage of poly- 
nuclear neutrophile cells. The total number of leukocytes tended 
to be high — up to 12,000. The red cell count A\'as frequently slightly 
reduced. Except for lymphocytosis in 1 case of hypophyseal adiposity 
and in 2 adipose eunuchs, the author has been unable to find reports 
of blood examinations in adiposity in the literature. Under the influ- 
ence of thyroid tablets, the lymphocytosis observed by him decreased 
or disappeared, and there AA'as a corresponding increase of the neutro- 
philes, in a fcAV cases in A\'hich the gland A\'as administered. _ Kocher 
has obserA'ed similar blood changes in myxedema after administering 
thyroid gland — ^for here, too, in untreated cases there is a lympho- 
cytosis. 



SLTRGERY 


137 


SURGERY 


UNDER THE CHARGE OF 

J. WILLIAM WHITE, M.D., 

FOKMEBLT JOHN RHEA BARTON PROFESSOR OP BHROERY IN THE UNIVERSITY OP PENNSYLVANIA 
AND SURGEON TO THE UNIVERSITY HOSPITAL, 


AND 

T. TURNER THOMAS, M.E., 

ASSOCIATE PROFESSOR OF APPLIED ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON , 
TO THE PHILADELPHIA GENERAL HOSPITAL AND ASSISTANT BURGEON TO THE 
UNIVERSITY HOSPITAL* 


A Procedure for "Wide Extirpation of Cancer of the Prostate 
Gayet, Champel, and Fayol {Jour. d’Urolog., 1913, iii, 333) say 
that up to the present time three perineal paths have been employed 
for the removal of a cancerous prostate. These they designate as the 
anterior, middle, and posterior. The anterior is through the anterior 
triangle of the perineum. In the middle, which is more frequently 
employed, a transverse incision is made between the two tuberosities 
of the ischium. In the posterior the incision is made from the tuber- 
osity of the ischium to the coccyx. Gayet, Champel, and Fayol 
utilize the whole length of the perineum, the incision passing well to 
the left side of the anus. The following is a brief outline of the opera- 
tion which they describe; The patient is placed in the lateroventral 
decubitus or the pelvis maj'’ be extremely elevated so that the perineum 
looks toward the ceiling. The incision which passes from the root 
of the penis to the coccyx is deepened and the rectum separated and 
pushed posteriorly. The posterior surface of the prostate, the seminal 
vesicles and the posterior inferior surface of the bladder are then 
exposed. If the lateroventral position has been employed, this is now 
changed to the dorsal with extreme elevation of the pelvis. The perineal 
floor is now divided in its Avhole length and the rectum is pushed 
further backward and to the right side. The finger recognizes the 
apex of the prostate and membranous urethra which is easy if a sound 
or catheter has been placed in the urethra. The urethra is opened in 
front of the apex of the prostate and through this opening an elbowed 
retractor is introduced. The urethra is divided transversely in 
its whole circumference and the prostate is separated from the sur- 
rounding structures by scissors, the hemorrhage being controlled by 
a gauze tampon. If the prostate can be depressed far enough, a 
puncture is made by a bistoury through the anterior wall of the bladder 
above the portion invaded by the tumor. This opening is enlarged 
on both sides by scissors, giving a wide opening into the bladder. 
The posterior portion of the bladder in the region of the trigone and 
meters is now well exposed. With catheterization of the ureters, the 
lest of the separation of the prostate and tumor can be completed under 
the guidance of the eyes. The separation of the divided ends of the 
urethi’a and bladder is considerable, but their elasticity aided by a. 



138 


PROGRESS OF MEDICAL SCIENCE 


moderate liberation of the urethra permits them to be brought together 
by sutures. But it is not necessary to suture them together in their 
whole circumference, a large opening in the bladder being left pos- 
teriprly. Through this opening a large tube is passed and fixed in 
position Avith a catgut suture. The muscles of the perineum are then 
restored A^ery incompletely and a large drain is introduced penetrating 
to the side of the vesical tube. The skin margins are then brought 
together, leaving a large median opening for gauze drainage. The 
results of this operation in two cases were benign. At the end of 
five Aveeks in the first patient all urine passed in the natural Avay and 
in the second patient more quickly, Avithout the necessity of catheteri- 
. zation or dilatation. 


Traumatic Epilepsy after Head Injuries in the Japanese -Russian 
War.— Eguchi {Betdsch. Zeitschr. /. Chir., 1913, cxxi, 199) says that 
head injuries frequently produce traumatic epilepsy. From 1.3 to 
4.7 per cent., on the aA^erage 3 per cent., of all skull injuries admitted 
to the reserve hospitals of Japan during the Avar Avere followed by 
traumatic epilepsy. In these, injuries of the bone and dura mater 
produced irritation of the brain. Wounds of the soft tissues alone 
gave no cases of epilepsy. The symptoms folloAved not only injuries 
of the cortex in the motor area, but many times injuries in other areas. 
The traumatic epilepsy appears usually after cicatricial tissue deA'^elops, 
Its occurrence at an earlier stage is A^ery rare. It AA^as more frequent 
after sagittal than after transA'erse gun-shot AAmunds. The frequency 
AA’^as in proportion to the size of the brain injury. The autopsy did not 
shoAV in any case any changes in the medulla, pons, or cerebellum. 
Scars of the head are A'ery irritable in cases of traumatic epilepsy, and 
are A’'ery tender on palpation. If a bone defect is coA’^ered only with 
a flap of soft tissues, the pulsation of the brain can be seen. The soft 
tissue flap used corresponded to that of Kocher. Adhesions betAA^een 
the dura or skin and the brain frequently produce epilepsy, as does 
traumatic neAV formation, such as thickening of the inner table of the 
skull, cj^sts, abscesses, etc. Foreign bodies, pieces of bone, and in 
AA^ar especiallj", splinters of bone or pieces of missiles, cause epilepsy 
by pressure on the dura and brain. All of Eguchi ’s cases dcA^eloped 
a nerAmus disposition. Epilepsy dcA^elops easily after head injuries 
in nerAmus people. The shortest period from the day of the injury 
to the beginning of the epilepsy Avas 3 days, the longest AA^as 442 days, 
the average 161 days. Medicines, especially the bromides, cannot 
suppress the attacks before operation, but after operation has been 
done the attacks, AA^hich recur in some cases, can be more quickly 
controlled by the bromides. Operation gave good results in Eguchi’s 
cases. A cure AA^as obtained in 11 cases, or 90.9 per cent., and no results 
in 1 case, or 9.1 per cent. The death in this last case was not the 
result of the operation, but of the bursting of an aneurysm. In aU of 
the other cases no attack had occurred tAvo years after operation. 
One should operate on all cases of traumatie epilepsy from head 
injuries in Avhich he detects scars, or wounds, or other changes. _ If 
the epilepsy developed a short time before the operation, a quick 
result should be expected. If the attacks have been occurring for a 
much longer period, the operation may be foIloAved by several attacks. 



SURGERY 


139 


Partial convulsions disappear more quickly after operation tlian general 
convulsions. In operating, two kinds of flaps may be employed, 
without a bone defect, like that of Wagner, and with a bone defect 
covered by a soft tissue flap. Pieces of bone, foreign bodies, and 
bone thickening should be removed. Adhesions should be separated 
between the skin and bone, bone and dura, and dura and brain. The 
dura may be excised. Cysts and abscesses should be incised and 
scars excised. 

Treatment of Spontaneous Gangrene of the Extremities. ^Koga 
{Dmtsch. Zeitschr. f. Cliir., 1913, cxxi, 371) says that spontaneous 
gangrene of the extremities from arteriosclerosis in the young is more 
common in Japan than in Europe. His chief, Ito, attributed this to 
the greater use of a vegetable diet in Japan. Until the present time 
we have been almost powerless to prevent threatening angiosclerotic 
gangrene, or to restrain it Avhen it develops. The results of arterio- 
venous anastomosis have not been favorable. In only 8 out of 63 
cases collected by Zesas was improvement or a cure obtained. Koga 
has tested the viscosity of the blood in a series of cases of spontaneous 
gangrene and found it almost always of much value. Reduction of 
the increased viscosity by saline infusions influenced the gangrene 
favorably. The administration of potassium iodide had little or no 
effect on the gangrene. Koga reports 13 cases, varying in age from 
twenty-four to forty-eight years. He determined nothing definite 
as to the etiology, and the urine contained nothing abnormal and 
particularly no sugar. Syphilis was always excluded, the Wassermann 
reaction being negative in every case. They were cases of presenile 
gangrene, in which the viscosity was increased, as a rule, and was 
reduced to the normal by the saline solution. Simultaneously the 
symptoms improved, the edematous swelling decreased, as did the 
cyanosis, and a sharp line of demarcation developed. Ulcers became 
clean and cicatrized, and the pulsation of the arteries which could 
not be felt before the introduction of the saline infusion, reappeared. 
The pain also disappeared so that the patient could sleep, the feeling 
of cold was not complained of, and the patient could walk a consider- 
able distance. The blood, having its viscosity reduced, gets through 
the vessels easier and then favors the development of collateral 
branches. Koga believes that the condition of sclerosis is improved. 
He reviewed his cases last December, by mail, and found that the 
improvement or cure had lasted a variable period. In one case ampu- 
tation had been done for recurrence. In another a black spot had 
appeared on the same foot. Repeated infusions might have prevented 
the recurrences. The effect of the infusions on spontaneous gangrene 
does not appear to be of short duration. 


Paralysis of the Phrenic Nerve from the Employment of Kulen- 
kampff’s Brachial Plexus Anesthesia.— Seivers {Zcntralhl. f. Chir., 
1913, xl, 338) reports the following experience following the injection 
of the brachial plexus above the clavicle for anesthetization of the 
upper extremity. It was done for the treatment of a wound of the 
soft tissues on the ulnar side of the right hand, in a healtliy young 
man, and 20 c.c. of a 2 per cent, novocain bicarbonate solution was 



140 


PROGRESS OF MEDICAL SCIENCE 


injected. The anesthesia was sufficient at the end of a quarter of an 
hour to permit the operation to be completed without further anes- 
thesia, although the radial side of the hand was not completely anes- 
thetized. At the beginning of the treatment of the wound the patient 
began to complain of severe pain in the right side of the chest, which 
increased during the operation. The breathing was inhibited as in a 
dry pleurisy, every deep inspiration being prevented. The Rontgen 
rays showed at first almost complete arrest of movement in the right 
half of the diaphragm. Later there was slight movement of this 
side, but considerably less than on the left side. The condition remained 
unchanged for several days except that the pain became less, and 
the disturbances disappeared in about four days. Three explanations 
are offered for the development of this paralysis of the phrenic nerve: 
(1) It majr have been due to an endoneural injection of the cervical 
portion of the phrenic; (2) to a subfascial diffusion of the anesthetic 
fluid to the nerve; (3) or to an extension of the fluid to the apex of the 
pleura. Seivers favors the third explanation. The apex of the pleura 
lies just underneath the brachial plexus and a considerable quantity 
of the anesthetic fluid is injected, so that it could easily extend along 
the loose connectiA'^e tissue over the pleura to the phrenic nerve, which 
passes downward on the anterior and mesial surface of the pleura. 
This complication is not, however, a contraindication to this method 
of anesthetizing the upper extremity. It may be serious, however, 
in affections interfering with the respiratory organs, since the inter- 
ference Avith expiration and coughing might lead to retention of the 
secretions and pneumonia. Kulenkampff called attention to the 
possibility of a paralysis of the phrenic nerve in the employment of 
his method of injecting the plexus. 


The Extended Abdominal Radical Operation for Cancer of the 
Uterus. — Weibel (Swrg., Gyncc., and Obst., 1913, xvi, 251) saj’^s that 
in criticizing the value of the operation we should first calculate hoAv 
many of all cases subjected to the radical abdominal operation are 
free from recurrence at the end of five years (after results), and then 
calculate how many of all cases examined in the clinic (including 
the inoperable ones) are well and free of cancer at the end of five years 
(absolnte percentage of cures). The after results Avere calculated as 
folloAA^s: 380 cases were operated, 8 of these died from intercurrent 
diseases, and 160 were Avell and free of recurrence; therefore, 43 per 
cent, of all operated cases could be permanently cured. If the primary 
deaths were left out of the calculation (because they cannot come into 
consideration AA'ith respect to the after results), Ave haA'^e 53 per cent, 
permanent cures of all cases surviA'ing the operation. Calculating 
•the absolute efficacy he gets the following results: 863 cases Avith 
cancer of the cervix Avere examined in this fiA'^e-year period, 36 of them 
refused the proposed operation, and 8 died from intercurrent diseases; 
from the rest (819) 160 cases AA'ere well and free of cancer. _ It is 19.5 
per cent, absolute efficacy, 1 per cent, more than he had in his first 
250 cases. With these results Ave can say that the radical abdominal 
operation for cancer of the uterus cured permanently a fifth of all these 
cases examined in the clinic; it cured permanently 43 per cent, of all 
operated, and 53 per cent, of all cases surviving the operation. In 



THERAPEUTICS 


141 


the last 175 operations he has been able to reduce the primary, mor- 
tality to 9 per cent. The raising of the operability, the permanent 
falling of the mortality, and the increasing in the operative technique 
allow him to hope that he will be able to report much better results 
in the next years, when his present cases have passed the five-year 
limit. 


THERAPEUTIC S 


UNDER THE CHARGE OF 

SAMUEL W. LAMBERT, M.D., 

PROFESSOR OP APPEIED THERAPEUTICB IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 
COLUMBIA UNIVERSITY, NEW YORK. 


Syphilitic Disease of the Aorta. — ^Deneke (Dcvtsch. med. Wocli., 
1913, xxxix, 441) believes mercury is a more reliable remedy for the 
treatment of syphilitic aortitis than salvarsan or neosalvarsan. He 
advises giving a combination of mercury and iodide Avhen the Wasser- 
mann reaction is positive and iodide alone when the reaction is nega- 
tive. He says that salvarsan should not be given to patients Avith 
serious aortitis and great caution is necessary Avlien giAung it to patients 
Avith the milder forms of aortic disease. He gives salvarsan only in 
small doses from 0.2 to 0.4 gram, and ahvays Avith mercury or the 
iodides. The guide as to the length of treatment is the Wassermann 
reaction, and this should become permanently negative before treat- 
ment is discontinued. This result may never be obtained, but tlie 
treatment should be persistent. Temporary improvement often 
folloAvs antisyphilitic treatment in cases of aortic disease, but perma- 
nent results depend upon the thoroughness of the treatment. 


Action of Benzol on Leukemia. — ^Keein {Wien. klin. Woch., 1913, 
xxiv, 357) has treated 22 cases of leukemia Avith benzol in the past 
six months. The details of 12 cases are giA'en in the article. He gave 
the benzol mixed Avith olive oil either in milk or in a capsule. His 
aA^erage dose AA^as less than 4 grams a day, and he thinks that the results 
Avere equally as good as Avith higher dosage. Doses as high as 5 grams a 
day were given in a fcAv cases, and it seemed that these higher doses 
had an injurious action on the red-blood corpuscles. He also injected 
the benzol subcutaneously in dosage of 1.5 grams once a day, mixed 
AA^ith an equal amount of olive oil. None of his patient showed any 
signs of irritation on the part of the kidneys. His results Avere not 
so uniformly favorable as those reported by ICiralyfi, ICoranyi, and 
others, but he thinks that benzol is a decided aid in the treatment of 
leukemia. The best results Avere obtained AAdien the benzol treatment 
bad been preceded by a course of .r-ray treatment. He adAmcates 
the combination of these treatments in all cases of leukemia, especially 
for those Avith very high leukocyte count. No difference in the 
effect was noted in the various forms of leukemia. 



142 


PROGRESS OF MEDICAL SCIENCE 


Treatment of Leukemia with Benzol.— Stern (Wien. Idin. Wocli., 
1913, xxv'i, 365) reports a case of leukemia of recent origin treated 
with benzol. The dose was begun at 3 grams a day in capsules with 
an equal amount of olive oil and ivas increased to 6 grams a day. 
At the end of two months the leukocyte count had diminished from 
264,000 to 13,300, and the red-blood cells had increased from 3,500,000 
to 5,500,000. The differential count changed as follows: Myelocytes 
diminished from 44 per cent, to 3 per cent.; polynuclear leukocytes 
increased from 48 per cent, to 74 per cent. The spleen decreased in 
size in proportion to the improvement in the blood picture, until at 
the end of the treatment it was normal in size. The patient’s general 
condition improved, the weight increased, and the result seems to be 
an apparent cure after two months of benzol treatment. Stern says 
that of course it is too soon yet to say this is a permanent eure. 

Experiences with Neosalvarsan. — Lier {Wien. Idin. rFoc7f.,1913, 
xxvi, 410) draws the following conclusions from his experience with 
neosalvarsan. Neosalvarsan is especially indicated in those cases in 
which mercurial treatment leads to severe stomatitis or nephritis. 
In such cases neosalvarsan can be injected repeatedly without periods 
of interruption of the treatment as is necessary with mercurial treat- 
ment. Neosalvarsan may be given intramuscularly because of its 
easy solubility in water and neutral reaction. The intramuscular 
injections are very little or not at all painful and they do not leave 
areas of infiltration at the site of injection. Lier also believes that 
neosalvarsan can be used with safety in ambulatory cases. He believes 
that neosalvarsan gives the best results in primary to tertiary syphilis, 
but that it is also of value in the infectious wet form of the secondary 
stage. In the dry form of the secondary stage the action of neo- 
salvarsan is weaker than that of mercury, and in these cases it should 
be used always in combination with mercufy. When neosalvarsan 
is given in combination with mercury the individual injection should 
be given at longer intervals. Lier believes that neosalvarsan is often 
able to effect a true abortive cure in primary syphilis if given in large 
doses at frequent intervals. He also advises a combined neosalvarsan 
and mercurial treatment in early metasyphilitic diseases of the nervous 
system. 

The End -results of the Abortive Treatment of Syphilis with Sal- 
varsan. — Muller {Munch, med. Woch., 1913, lx, 408) writes coneerning 
39 cases of primarj'^ syphilis treated during 1910 and 1911 hy what 
he terms the abortive treatment of syphilis. This treatment comprises 
excision or cauterization of the primary lesion, three intravenous 
injeetions of salvarsan of 0.4 gram each, and five injections of 40 per 
cent, calomel in oil (0.5 to 0.07 gram) and 40 per cent, mercurial 0.1 
to 0.14 gram. Nine of these cases disappeared from observation, but 
in the 30 cases observed up to the present time none has shown any 
clinical manifestation of the disease, and the Wassermann reaction 
remains persistently negative. 

Cholesterin in Paroxysmal Hemoglobinuria.— Pringsheiri {Med. 
Klin., 1913, ix, 254) tried cholesterin in the treatment of paroxysmal 



THERAPEUTICS 


143 


gemoglobinuria on the. ground that cholesterin has been found to 
have an inhibitory action on hemolysis in test-tube expeiirnents. 
He found that it did abort the attacks and that when it was discon- 
tinued the attacks recurred as before. He gave the remedy by intra- 
muscular injections of 5 c.c. at a dose of a 10 per cent, emulsion of 
cholesterin. No appreciable changes were observed in the blood 
during the cholesterin treatment. The remedy did not have any 
permanent effect, however, for a severe and typical attack occurred 
a week after discontinuing the cholesterin. 

The Treatment of Amebic Dysentery with Subcutaneous Injections 
of Emetin Hydrochloride. — Lyons (Jour. Avicr. Med. Assoc., 1913, lx, 
1216) reports 6 cases of amebic dysentery treated by hypodermic 
injections of emetin hydrochloride, 5 of which recovered promptly. 
Lyons says that the 1 fatal case should be omitted in judging the 
treatment, as the patient was beyond hope of cure by any method of 
treatment. The largest dose used was three-fourths of a grain. The 
average length of treatment until the stools became normal was nine 
days for the 5 cases. Lyons says that larger doses may be found more 
effective. There were no ill effects noted from, the use of the remedy. 
He believes the treatment of amebic disease with emetin rests on an 
experimental basis. It has been shown that ipecacuanha without 
emetin has but little effect on ameba in vitro (as well as clinically), 
while emetin has a most powerful amebicidal action. Granting this, 
then we may assume that emetin is the active principle of ipecac so 
far as amebas are concerned, and theoretically should be used in 
preference to the whole drug in the same manner as we employ quinine 
for the treatment of malaria in preference to cinchona. According to 
Rogers a third of a grain of emetin is equivalent to 30 grains of ipecac. 
The soluble salts of emetin are put up by several pharmaceutical 
houses. The hydrochloride, to which Lyons experience is limited, is 
practically non-irritating when used subcutaneously, and in moderate 
doses causes no nausea, vomiting, or depression. Rogers’ largest 
dose was 3 grains in one day. Allen injected 4 grains at one dose and 
produced nausea for several hours — the patient vomiting once. Rogers 
has given the hydrochloride intravenously (1 grain in 5 c.c. of normal 
saline solution) without any depressing effect on the pulse. To sum- 
niarize,^ the advantages of the emetin treatment are briefly: (1) 
Simplicity and ease of administration of the drug; (2) no vomiting or 
depression; (3) accurate dosage; (4) rapid absorption and effect; 
(5) reliability of product against the marked differences in the strength 
of powdered ipecac from, different manufacturers. Lyons says that 
while no definite conclusions can be drawn from the observations of 
so small a number of cases, he believes that the results are highly 
suggestive that in the subcutaneous injections of soluble emetin 
^Its an ideal method has been found of treating amebic disease. 
Time will soon show whether or not, as Rogers believes, another specific 
has been found. 


Amebic Abscess of Liver Treated Successfully by Emetin. — 
Chauffard (Bull. d. I’Acad. d. Medicine, 1913, Ixxvii, 122) reports a 
case of a large amebic abscess of the liver that after about a year per- 



144 


PROGRESS OF MEDICAL SCIENCE 


forated into a bronchus. When the emetin treatment was begun the 
patient had been for five months raising a . eonsiderable amount of 
reddish pus averaging each day from 200 to 250 c.c., and during this 
time had become^ emaciated and septic. At the same time there was 
some ulceration in the rectum. The a:-ray examination showed an 
opacity at the base of the right lung merging with the shadow of the 
liver. The patient was given six injections of emetin hydrochloride, 
each 0.04 gram, during a period of five days. The injections were 
practically painless and produced no local induration. The expec- 
toration was reduced to but a slight amount on the fifth day of the 
treatment, and after that it stopped entirely. The temperature fell 
to normal and the leukocyte count dropped from 49,000 to 19,800, 
and the polynuclear from 77 per cent, to 63 per cent. The ulceration 
in the rectum healed and subsequent .r-ray examinations showed that 
the base of the right lung had cleared up. The patient improved 
markedly in general health and increased in weight 13 pounds. Chauf- 
fard believes that his experience with the clinical results reported by 
others demonstrates that emetin is a specific for amebic disease like 
quinine for malaria. 


PEDIATRICS 

UNDER THE CHARGE OF 

LOUIS STARR, M.D., and THOMPSON S. WESTCOTT, M.D., 

or rHILADELFDIA. 


Chronic Infective Endocarditis. — Edmund Cautley (Archiv. of 
Pediatrics, 1913, xxx, 328) offers the histories of a number of cases of 
this kind, with comments on each. This disease is infrequent in older 
children and young adolescents, is acute in tj^pe, and recovery is 
exceptional. The following cases are in accordance with the estab- 
lished opinion that infectwe endocarditis is secondary to pre-existent 
valvular disease and maj^ affect any valve: An instance of the p^’^emic 
type affecting the tricuspid valve occurred in a young adult. After 
thi’ee months in the hospital the patient was discharged cured, except 
for a permanent tricuspid regui-gitant murmur. A case, secondary 
to mitral valvular disease, in a girl, aged sixteen years. Death occurred 
from rupture of an aneurysm of a cerebral artery eaused by an embolus. 
A case secondary to rheumatic fever and congenital heart disease in a 
girl, aged fifteen years. Death occurred from recurrent hemoptysis 
due to emboli carried to the lungs. A case affecting the aortic valves, 
probably secondary to a previous heart condition in a boy, aged eight 
years. Death occurred from meningitis in eleven days, probably from 
infection carried from the heart. Death results more commonly 
from secondary effects such as cardiac failure or infarction rather 
than from toxemia. This is illustrated by two cases. One case of 
clnronic infective endocarditis of the pulmonary valve in a child, aged 
eight years, was in the hospital eight months. Death was caused 



PEDIATRICS 


145 


by thrombosis of the pulmonary artery, caused partially by prolonged 
toxemia and wasting. . Fever and wasting were constant and prolonged. 
The spleen was much enlarged. A reduction in fever occurred with the 
onset of edema and ascites. Serum and vaccines were valueless. The 
other case was in a boy, aged eighteen years, in whom the tricuspid 
and aortic valves were involved. Death was due to a terminal infec- 
tion of the lower lobe of the left lung and secondary cardiac failure. 
The spleen was much enlarged but the degree of fever less than in the 
first case. A streptococcus was found in the blood but autogenous 
vaccines were useless and the streptococcus was probably due to the 
terminal infection. Serum and vaccine treatment are practically 
hopeless, except they may in some cases enable the body to destroy 
the infective agent if given very early. Quinine, arsenic, iron, and 
perchloride of mercury are of value. 

Diphtheritic Paralysis. — ^J. D. Rolleston (Archiv. of Pediatrics, 
1913, XXX, 335) reports his findings in a study of 2300 cases of diph- 
theria with especial reference to diphtheritic paralysis. He found it 
exceptional for paralj'sis to develop after the sixth week. Of the 2300 
cases, 20.7 per cent, showed some form of paralysis. In each series 
of 100 cases the percentage of paralysis was never less than 10 or more 
than 31. He shows that there exists a close relation between the acute 
attack and the subsequent paralysis. The more severe the acute 
attack the more frequent and severe the subsequent paralysis. Where 
the nostrils as well as the tliroat are affected the incidence of paralysis 
is greater than when the fauces alone are affected. Pure nasal or 
laryngeal cases showed practically no subsequent paralysis. Affection 
of the tendon jerks and the presence qf Babinski’s sign is more common 
in severe than in mild attacks. But 1.3 per cent, of the cases showed 
a relapse and none of these cases developed paralysis. Second attacks, 
varying from three months to fourteen years, were found in 2.1 per 
cent, of the cases. Paralysis was more frequent in children than in 
adults, the majority occurring between two and six years of age. 
Early injection of antitoxin undoubtedly jugulates the disease, and 
minimizes the occurrence of complications. Cardiac and palatal 
paralyses are the only ones occurring during the first fortnight. After 
this time no serious palsy occurs, as a rule, until the fifth week. During 
the fifth and sixth weeks other palsies develop, such as ocular, dia- 
phragmatic, etc. In this series 85 deaths were due to paralysis. The 
prognosis is better in older patients. There was no fatal case above 
the age of thirteen years. Cardiac, phaiyngeal, and diaphragmatic 
palsies are the only kind which may cause anxiety. A well-marked 
serum reaction at the usual period after injection is a favorable omen. 
It is exceptional for cardiac paralysis to be fatal in these cases. In 
severe cases the patients should not be allowed to sit up for six weeks. 

Summer Heat and Summer Diarrhea. — Hector Charles 
Cameron {British Jour. Child, Dis., 1913, x, 205) believes that this 
subject has been dealt with too exclusively from the point of view of 
the epidemiologist.^ All factors in the etiology of summer diarrhea 
^her than microbic contamination have been too much neglected. 

^ven if we could secure a faultless supply of milk we should still 



146 


PROGHTSSS OF AIEDICAL SCIENCE 


Avitness an enormous rise in the frequency of diarrhea as a symptom 
during hot Aveather, Heat may'haAm a direct effect on the infant, 
increasing the amount of summer diarrhea. The increase may be 
due to indirect effect of the heat by loAvering, the tolerance to food, 
by increasing the danger of o\mrfeeding in a thirsty infant, by loAvering 
the immunity of the child to infections, and by aggraA'^ating the course 
of all alimentary and infectious disorders of AvhatCA^er nature. Heat 
may exert an indirect effect by faA'oring the multiplication of micro- 
organisms AAuthout the body. If the cause of summer diarrhea is to 
be found in the multiplication of bacteria in milk, then some explana- 
tion must be found for the frequency AAuth AAdiich breast-fed infants 
are attacked and for the high mortality among babies fed on con- 
densed milk and patent foods, in Avhich the bacterial content is rela- 
tiAmly loA^^ A A*ast amount of bacteriological Avork has not succeeded 
in establishing a causal relation betAA'een any one organism and so- 
called epidemic diarrhea. In the rise in incidence of .summer diarrhea 
all the factors mentioned haAm a part, and of all deaths registered 
as due to diarrhea in the summer, a small fraction only is due to 
bacterial infection of the alimentary tract. Greater emphasis should 
be laid on prophylactic measures such as an adequate quantity of 
AA'ater, reduction in carbohydrate food, cooling baths, light, porous 
clothing, and proper A’-entiiation. 


O BSTETRICS 


UNDER THE CHARGE OF 

EDWAED P. DAVIS, A.M., M.D., 

PROFESSOR OF OBSTETRICS IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 


Albuminuria Likely to Eecur in Successive Pregnancies, — Under 
this title Slemons (A??ic'r. Jour, of Obstct., Ma}", 1913) discusses the 
question of prognosis in cases Avhich haA'e suffered from albuminuria 
and toxemia in the first pregnancy. From clinical records it appears 
that but one in six patients avIio liaAm had this complication in their 
fii’st pregnancy may expect its recurrence in subsequent parturition. 
Lapage {Annali di ginecologia d’Obstct., 1912, p. 577) and Williams, 
arriA'e at practically the same conclusion, as among hospital cases 21 
per cent, suffered a recurrence of albuminuria and toxemia after the 
first pregnancy. In the effort to distinguish betAveen those patients 
Avho are likely to have danger and those aaFo are not, the clinical 
course of the tAVO types of auto-intoxication must be studied. A severe 
attack of scarlet fever in childhood greatly influences the prognosis. 
Severe toxemia tends to recur in successive pregnancies Avith increased 
Aurulence, and more early in the course of gestation. Where repeated 
toxemia terminates fatally the kidneys are usually found to be involved. 
It is sometimes possible to base a prognosis upon the conA^alescence 



OBSTETRICS 


147 


of tlie mother from the first auto-intoxication. If this is prolonged 
and imperfect, the outlook for the future is_ correspondingly bad. 
Slemons would classify cases of albuminuria with toxic symptoms in 
the later months of pregnancy into three groups; two are well defined 
and likely to suffer from recurrence, while the third will almost cer- 
tainly be exempt. He has not found the nitrogen partition to be 
useful in reaching a prognosis, but he believes that the estimation of 
the quantity of albumin is helpful. The greater it is and the longer it 
persists, the more extensively are the kidneys damaged. In cases 
where the liver seems especially involved and the kidneys normal, the 
prognosis as to recurrence is good. Blood pressure is more satisfactory 
than albumin as an index, and upon this basis cases may be divided into 
three groups. In nephritic toxemia a pressure of 250 m.m. is frequently 
observed. In toxemia it is at its height; the pressure Avas rarely beloAv 
180 m.m. In cases studied from this basis, 75 per cent, of patients 
having eclampsia are not likely to do so again; while in 15 per cent, 
extensive lesions of the kidneys made the prognosis bad; 10 per cent, 
of toxemic cases are uncertain as to prognosis. Chemical methods 
in estimating the efficiency of the kidneys have proved disappointing. 
Slemons concludes that at present we have no better clinical methods 
for deciding the nature of a toxemia and of reaching an ultimate 
prognosis in the study of the albumin and blood pressure during 
convalescence. In nine out of ten cases a satisfactory conclusion 
can be reached from this data, and auto-intoxication does not return 
in approximately 80 per cent, of cases. 

Abderhalden’s Serum Test for Pregnancy. — Behne {Zcntralhl. f. 
Gynah., 1913, No. 17) has tried Abderhalden’s method of dialysis in 
the diagnosis of pregnancy in the clinic at Kiel. His observations in 
44 cases show that this test gives regularly a positive result in normal 
pregnancy. In advanced gestation, in some cases the results are 
negative. Patients who are not pregnant but Avho suffer from an 
inflammatory condition of the genital organs, with the production of 
pus or Avith suppuration in some other portion of the body, as in the 
breast, often give a positive reaction. In the differential diagnosis 
betAveen ectopic gestation and inflammatory conditions of the adnexa, 
the _ test by dialysis does not give a definite differential diagnosis. 
PositiA^e reactions are obtained AA'ith serum in pulmonary tuberculosis 
and diseases of the liver. 


Puerperal Eclampsia.— Gibbons {British Med. Jour., April 26, 
1913) reAueAvs to a considerable extent the literature of the subject 
and states that Ave knoAA^ of nothing Aidiich can definitely be described 
as the cause of the disease, although all cAudence goes to sIioaa’^ that it 
is a poison circulating in the blood. Rapid emptying of the uterus 
by the most safe method aA^ailable, after the first few convulsions, 
seems to giA'^e the best prognosis. The greater the delay the greater 
Avill be the danger to the mother. 


Unusual Fertility in Syphilitic Patients, with Anomalous Involve- 
ment of the Child.— Watcon (British Med. Jour., April 26, 1913) 
reports the remarkable instance of the family of a AA'^andering gypsy. 



148 


PEOGRESS OF MEDICAL SCIENCE 


the mother of the family having brought one of iier children for exami- 
nation. Multiple dactylitis Avas present, of syphilitic origin. On 
examination, the mother vas aged twenty-one years, well nourished, 
and gave a negatiA’e history-, believing that she had ne\-er had A'eiiereal 
disease. On e.xamination, there was a scar on the right labium. She 
had three times given birth to twins, without miscarriages. All of 
the children ivere born prematurely, the first pair at the seventh 
month, and the others at the eighth month. The first tAvins were 
normal in size, the others smaller. The father had undoubtedly had 
syphilis, and was fairly A'igorous, but was mentally deficient and 
seemed to be in the Amry early stage of general parah'sis of the insane. 
The first tAAuns seemed in perfect health and shoAved no cA'idence of 
syphilis. The second pair had thickening in the bones and dac- 
tylitis, and the parents stated that the children had eruptions on the 
buttocks when they were six weeks old. The third twins had a con- 
dylomas, sore eyes, and peeling of the skin of the hands and feet. 
There Avere also marked snuffles and a coppery eruption on the nates. 
The serum of the parents and children in each case gave a very positive 
result. This family of gA-psies were wandering about the eountry 
subsisting merely by selling tin cooking utensils AA'hich they made. 
They are a source of danger from infection and such indiAuduals should 
be segregated to preA'ent the danger of spreading sji^hilis in the 
community. 


The Condition of the Blood Serum of Mother and Fetus in the 
Pyelitis of Pregnancy. — Weivel {Archh f. Qyn'dh., 1913, cxix, No. 2) 
has studied the question of the formation of antibodies in the blood 
serum of mother and fetus in cases AA'here pregnancy AA-as complicated 
■ by pyelitis. He finds that the colon bacillus passing from the intes- 
tine into the urinary tract takes up its neAv functions and actiA'ities 
from the antibodies, and what he styles the third order may be detected 
in these cases; the reactions are not always typical, and the organisms 
haAung immunity show in A*arious cases great differences, AA'hich com- 
plicate the results of clinical and bacteriological examination. When 
antibodies were found in the serum of the mother, they Avere also 
present in the serum of her child or children. In some cases they Avere 
also present in the amniotic liquid in a greatly lessened quantity. 
In the serum of the fetus these bodies disappeared shortly after birth. 
It is eAudently not yet practical to employ this reaction in making a 
diagnosis of infection bj'^ the colon bacillus. 

Subcutaneous Symphysiotomy, — ^Kehrer {Archiv f. Gyndk., 1913, 
xcix. No. 2) reports 10 cases of subcutaneous symphysiotomy, which 
he performs under ether or chloroform anesthesia, or in some cases 
by spinal anesthesia. Under antiseptic precautions two fingers of the 
left hand are inserted in the A'agina and the urethra carried t6 one 
side. The clitoris and meatus are pushed, so far as possible, out of 
the way, and an incision made directly AA'ith the scalpel upon_ the 
middle of the symphysis. The under portion of the symphysis is 
separated through tAA'o-thirds of the Joint. The edge of the knife is 
then turned upward and the upper portion of the Joint seA'ered, AAhile 
the separation is made complete in the surrounding tissues by the 



gynecology 


149 


use of a smaller scalpel. When the ligamentum arcuatum is severed 
the pubic bones separate^ and the legs of the patient are rotated 
outward and somewhat inward by assistants, to prevent the lacera- 
tion of tissue. The wound is then packed with gauze and the extremities 
closed Avith metal clips. The bladder is then carefully emptied com- 
pletely by catheter, and the patient placed in bed, when pituitrin in 
some form is given by intramuscular injection. The upper portion of 
the patient’s body is slightly raised, the knees are brought together, 
the thighs bandaged, and the knees slightly separated as birth occurs. 
After the birth of the placenta a permanent catheter is placed in the 
bladder for several days. In 118 cases the maternal mortality was 
0.8 of 1 per cent., in comparison with 4.1 per cent, in 217 subcutaneous 
hebostiotomies. There Avas no fetal mortality. There is almost no 
hemorrhage in the operation, the Avound through the skin is exceedingly 
small, and the danger of wounding the surrounding tissues is Amry 
slight. In 60 per cent, of cases there Avas some injury to the crura of 
the clitoris, and hematoma formed; and in 30 per cent, of the cases 
thrombophlebitis complicated the puerperal period. No case of 
embolism Avas obserAmd. The operation finds an especial field in 
multiparre, and the best results are obtained Avhen the child is expelled 
spontaneously. If possible, delivery by operation should- be avoided, 
and some preparation of pituitrin, with possibly Walcher’s position, 
should be utilized for delivery. Uterine inertia is no contraindication 
to the operation, and it may be performed in pelves AAdiose true con- 
jugate is as loAv as 6.9 to 6.8 cm. If care is exercised in delivery and 
in separating the pelvis, the sacro-iliac joints may not be damaged, 
and a separation of the pubic bones greater than 3 cm. should not 
occur. The operation is indicated Avhere cases are suspected of infec- 
tion. The patients walk Avell after the operation, and infection does 
not occur more often than in other cases. The joints unite as well as 
does the pelvis after pubiotomy, and the pelvis remains someAvhat 
enlarged after the operation. No callus forms, as after hebostiotomy, 
and the permanent scar is very small. The one essential objection to 
the operation is the tendency for hematomas to form in tissues about 
the scA^ered ends of the joint. 


GYNECOLOGY 


TJNDEn. THE CHARGE OP 

JOHN G. CLARK, M.D., 

PROFESSOJl OF GYNECOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA. 


Intestinal Obstruction Due to Retroverted Uterus.^A case of acute 
intestinal obstruction due to the sudden incarceration of a loop of 
intestine behind a non-adherent, retroAmrted uterus is reported by 
Lefevre {Jour, de Med. de Bordeaux, 1913, xliii, 183). The patient 
had had for some years a markedly retroverted uterus, which, however, 



150 


PROGRESS OP MEDICAL SCIENCE 


gave only slight symptoms, until one day, when riding in a carriage, 
she received a severe jolt, following which she was instantly seized 
with violent abdominal pain. This continued, and soon vomiting 
came on, which later became fecal. Nothing was passed by the bowel 
for_ forty-eight hours, by which time the patient was in a critical con- 
dition, presenting all the classical symptoms of intestinal obstruction. 
Laparatomy revealed a collapsed cecum and large intestine, but the 
small intestine Avas enormously distended up to a point Avhere a loop 
dipped down into Douglas’ pouch behind the uterus; beyond this it 
also AA^as collapsed. Gentle traction Avas sufficient to bring the intes- 
tinal loop out of the small pelvis, Avhen there Avas an immediate passage 
of gas and fecal matter into the collapsed portion of the gut, and the 
condition Avas relieved. The patient made an uneventful recovery. 
Lefevre believes that at the moment the patient received the jolt 
in the carriage the uterus Avas bounced forAvard for a moment out of 
its position of extreme retroversion, giAung a loop of intestine the 
chance to slip doAvn behind it. This Avas then caught by the uterus 
dropping back against the sacrum, and as distention began to take 
place behind the point of impingement, intra-abdominal pressure 
Avas increased, and the caught loop of intestine still further compressed. 
The uterus Avas not pregnant, and Avas only slightly larger than normal. 


Prognostic Value of Leukocyte Count in Pelvic Suppurations. — 
A statistical study of 100 cases of suppurative conditions in the pelvis 
from Hunter Robb’s service in CleA^eland has been made by J. T. 
Smith {Sitrg., Gyncc., and Obst., 1913, xvi, 403) to determine if the 
pre-operative leukocyte count is of any value in forecasting the out- 
come of the case. Of course, in cases Avhere the leukocytosis, fever, 
and other symptoms more or less correspond, that is, Avith high 
leukocyte count and high fever, or AA'ith low count and slight fever, 
this point is not of especial significance, but it does furnish us. Smith 
thinks, Avith A’aluable data in that group of cases in Avhich the blood 
count and temperature record are at variance, that is, in patients 
Avith a high leukocytosis (over 14,000) and moderate fcA^er (beloAV 
101°), or coiiA^ersely, Avith a Ioav count (beloAV 14,000) and high fever 
(above 101°). In these instances Smith thinks the blood count is 
of more prognostic value than the temperature, since the recorded 
results in the 100 cases studied sIioav that some trouble arose in a 
majority of the cases of pus in the pelvis Avith a leukocytosis of above 
14,000, Avhereas only a small proportion of similar cases Avith a eount 
beloAv 14,000 dcA^eloped any postoperative complications; moreover, 
the mortality in the first group Avas 8 per cent., as opposed to zero 
per cent, in the second. 

Callous Ulcer of the Bladder. — Buerger {Med. Record, 1913, Ixxxiii, 
657) says that Avithin the past tAvo years he has seen 2 Avomen suffering 
Avith intense vesieal tenesmus, dysuria, great frequency and urgency 
of micturition, and pjmria, in Avhom the cystoscope revealed the cause 
of the trouble to be a solitary, callous ulcer of the trigone, a condition 
as to Avhose occurrence doubt has been expressed by a number of 
prominent urologists. In one of these cases fulguration Avas tried, 
but entirely Avithout success, and the author believes that Avhere the 



LARYNGOLOGY 


151 


process is deep-seated, has lasted for a long time, with the forrnation 
of phosphatic incrustations on the surface, neither the application of 
silver nitrate nor cauterization will have any beneficial _ effect. The 
symptoms are so intense as to demand in every case radical measures 
for their relief, and Buerger has devised a method of treatment which 
in the two reported cases was followed by excellent results. He intro- 
duces through the operating cystoscope a pair of flexible “punch- 
forceps” with cup-shaped jaws, directing them against the lesion in 
much the same way as an ureteral catheter. In each case the entire 
ulcer was excised by means of these forceps at one sitting, cutting 
well down into the underlying bladder wall; this procedure was fol- 
lowed by immediate amelioration of the symptoms, the condition 
rapidly progressing to complete cure. Subsequent cystoscopic examina- 
tion showed that perfect healing of the ulcer had taken place with 
complete restoration of the vesical mucosa. Pathological examination 
of the tissue removed showed a superficial deposit of urinary salts, 
then a la 3 ^er of necrosis and ulceration, and beneath this newly-formed 
connective tissue with active evidences of inflammation. 


DISEASES OF THE LAEYNX AND CONTIGUOUS 

STRUCTUKES 


UNDER THE CHARGE OF 

J. SOLIS-COHEN, M.D., 

OF PHILADELPHIA* 


Three Fatal Cases of Pneumococcal Infection of. the Throat. — 
Tweedie {Jour. Laryn., Rhinol, and Otol., April, 1913) places on 
record the details of a clinical condition which he had not otherwise 
seen, the mortality of which in his hands had been 100 per cent. Two 
patients represented the asthenic, and a third the sthenic type of the 
disease, the latter running a comparatively rapid course from its 
commencement up to the end. All three were characterized by their 
absolute lack of response to every kind of general or local treatment 
employed; and no cause or connection could be ascertained apart 
from the presenee of the pneumococcus in the throat which was present 
in large numbers in pure culture on the swabs or sputa. There was 
no apparent ulceration of, nor membranous deposit on the mucous 
membrane concerned, which was, however, intensely injected and 
edematous at the commencement of the illness. The main focus of 
the local lesion in each case appeared to the naked eye as an indolent, 
necrotic, more or less localized, sloughing area quite distinct from 
any pathological state usually associated with the term “abscess.” 
Up to the last few days of the disease there was no impairment of 
the appetite or malaise corresponding with the progressive weakness 
raised teipperature, or severity of the disease generally. 



152 


PROGRESS OF AIEDICAL SCIENCE 


Abnormal EpistaphyUan Tonsil —Dapitolo reports {Annales dcs 
Maladies de I’Oreille, du Larynx, du Ncz et du Pharynx, March 3, 1913j 
a case in a child, aged seven years, upon whom he performed a bilateral 
palatme tonsillectomy with adenectomy. Three months afterward 
he removed, with a cold snare, a tumor of the size and form of a large 
molar tooth inserted by a short pedicle, upon the superior surface 
of the soft palate. Histological examination showed that it was 
composed of lymphoid tissue, and Dapitolo believes that it was an 
adenoid hypertrophy, provoked by irritation from the operation. 

A Case of Mixed Tumor of the Soft Palate.— Alagna {Annales des 
Maladies de VOreille, du Lar., du Ncz et du PJiar., March 3, 1913) 
reports a man, aged fifty-five years, who had a voluminous tumor of 
the soft palate, with troubles in deglutition and nasal respiration. 
Histological examination showed that it was composed of a lipo- 
myxomatous tissue, the adipose cells of which were constituted by a 
mixture of ethers, glycerin, and cholesterine. 


Perforation of the Nasal Septum Due to Topical Action of Cocaine. 
— Chevallier (Revye Hehd. de Lar., d’Oiol. et de Rhinal., April 26, 
1913) presents a thesis on the subject of perforation of the septum 
due to the sniffing of cocaine which he has frequently observed in 
individuals who might be classed among degenerates, or who have 
lost their equilibrium. He has also noticed it very frequently among 
morphomaniacs. This perforation is alwaj^s localized upon a point 
of the septum corresponding with the cartilaginous skeleton, the 
quadrangular cartilage alone being involved in the necrosis. As to 
its etiology, the author contends that the leukocyte.^ are killed bi'^ 
the cocaine and become harder, and thus the}”^ clog and gradually 
obliterate the lumen of the capillaries, rendering definitive a local 
anemia which is originally produced temporarily. This anemia long 
kept up proceeds to a suppression of nutrition and to the mortification 
of the tissues which ultimately terminates in the necrosis. An eschar 
is produced, and its elimination is the first stage in the evolution of 
an ulceration. 


Chondrosarcoma of Nasal Passages. — M r. Herbert Tilley (Jour. 
Laryn., Rhinal., and Otol., April, 1913) presented to the Lar 3 mgological 
Section of the Royal Society of Medicine two remarkable photographs 
of a young lad^'^ of sixteen, with recurrence within a few weeks after 
recovery from a primary’’ operation, and a second recurrence after 
a second operation for involvement of the nasal septum and right 
ethmoidal regions. 


Bronchial Asthma Cured by Operations in Rhinopharyngeal Respi- 
ratory Tract. — Gogomann (Annales des Maladies de I’Oreille, du Lar., 
du Nez et du Phar., Januar^q 1913) reports the case of a man, aged 
thirty-five years, a subject of asthma. After destruction of a nasal 
sjmechia and of a deviation of the septum, the paroxj^sms of asthma 
were arrested; and thej’^ disappeared completely after ablation of 
tonsils containing caseous accumluations in the cr^’^pts. 



HYGIENE AND PUBLIC HEALTH 


153 


Topical Anesthesia in Sinus Operations— In a discussion on the 
technique of operations for perinasal sinusitis, Siebenmann {^nnales 
dcs Maladies de V Oreille, du Lar., du Nez et du Pharynx, January, 
1913) affirmed that local anesthesia predisposes to local suppuration, 
and impedes cure by first intention. Ritter reported that he had had 
a case of death seven hours after an operation as a result of anesthesia 
by morphine-scopalamin injection. 


HYGIENE AND PUBLIC HEALTH 


UNDER THE CHARGE OF 

MILTON J. ROSENAU, M.D., 

PJiOFESSOn OF PREVENTIVE MEDICINE AND HYGIENE, HARVARD MEDICAL SCHOOL, BOSTON, MASS., 

AND 

MARK W. RICHARDSON, M.D., 

SECRETARY OP THE MASSACHUSETTS STATE BOARD OF HEA'LTH. 


Chlorinated Lime in Sanitation. — Chlorinated lime or bleaching 
powder, popularly miscalled “chloride of lime,” is a very remarkable 
substance which is being used very widely, especially for the disin- 
fection of drinking-water supplies. The subject is summed up in a 
book entitled Chloride of Lime in Sanitation, by Albert H. Hooker 
(John Wiley & Sons, 1913). Ballard, in 1835, found chlorinated 
lime to be composed of: Calcium hypochlorate, Ca(OCl) 2 ; calcium 
chloride, CaCb; calcium hydroxide, Ca(OH) 2 . Subsequent investi- 
gations by Olding and other chemists have shown that calcium chloride 
and calcium hypochlorite do not exist as such in dry bleaching powder, 
but are found on dissolving it in water. Calcium oxychloride, CaOCb, 
is generally accepted to be the essential constituent of dry cHorinated 
lime, and calcium hypochlorite to be the active principle of the solu- 
tion. It is also now well understood that chlorinated lime in its indus- 
trial application of bleaching, deodorizing, or disinfecting does not 
act by its chlorine, but by its oxygen. The chemical action is not 
“chlorination” but “oxidation.” Hypochlorous acid (HOCl) is 
probably the most powerful oxidizing agent known to chemists, and 
is readily^ broken up into hydrochloric acid, and liberates nascent 
oxygen with extreme readiness. Hooker gives convenient methods 
for making standard solutions of chlorinated lime, with useful tables, 
comparing parts per million with grains per gallon, expressed in terms 
of bleach and in terms of available chlorine. As a practical process 
the use of chlorinated lime for the disinfection of water dates from 
1908, when Mr. G. A. Johnson was called .to remedy some serious 
trouble in the water purification at the Chicago stock yards. Filtra- 
tion of the water of Bubbly Creek was not satisfactory, and Mr. 
Johnson substituted chlorinated lime for the copper sulphate winch 
had been used. Chlorinated lime is now used by many municipalities 
to render their public water supply safe. In some places it is used in 



154 


PROGRESS OF MEDICAL SCIENCE 

conjunction with alum coagulation and sedimentation or slow sand 
nitration; in fact, it may be used either alone or as an accessory to 
other methods. Following is a partial list of cities now using hypo- 
chlorite of lime in their drinking water supplies: New York, 16 
pounds per million gallons; Omaha, 1\ pounds per million gallons 
after coagulation and sedimentation; Cincinnati, 5 to 12|- pounds— 
typhoid rate reduced to 5.7; St. Louis; Minneapolis, after mechanical 
filtration; Toronto, 6 pounds; Montreal, 5 to 1\ pounds; Cleveland, 
16 pounds; Erie, 7 to 10 pounds; Chicago; Milwaukee, 6 pounds; 
Pittsburgh, 3 pounds, after slow sand filtration; Jersey City, 5 to 8 
pounds; Council Bluffs, 15 pounds, following alum precipitation; 
Brainerd, Minn.; Ridgeway, N. J.; Corning, N. Y.; Nashville, Tenn., 
14 pounds; Grand Rapids, Mich.; Little Falls, N. J.; Harrisburg, Pa.; 
Baltimore, Md.; Niagara Falls; Toronto; Ottumwa, Iowa, and others. 
It is important to remember that in Avaters treated with chlorinated 
lime, free chlorine never is present. While the chlorinated lime kills 
bacteria in the amounts used, it does not purify organic matter, cure 
discoloration, turbidity, or neutralize tastes and odors in the water. 
The remarkable germicidal power of chlorinated lime is better under- 
stood Avhen it 4S known that three grains of a practically harmless 
substance will kill myriads of bacteria contained in a barrel of water. 
Ordinarily the amounts used arc from one to two or five parts per 
million parts of water. Much more is recpiired in sewage. A bacterial 
reduction of 99 per cent, may be obtained in a water containing little 
organic matter, with one part per million, Avhereas it requires 1 part 
to 25,000 parts of sewage to affect a similar bacterial reduction. In 
practice, tlie average amount of bleach used in Avater purification is 
from 5 to 12 pounds per million gallons of Avater. The bleach cannot 
be detected by the sense of ta.ste, provided the amount does not exceed 
25 pounds. While the chlorinated lime treatment of Avater supplies 
is essentially simple, yet it requires able professional supervision else 
disappointing results Avill come from haphazard Avork. The great 
essential is a uniform dosing of a standard solution. Bleaching powder 
is also used in the disinfection of the water of sAA’imming pools, for 
street sprinkling, and flushing, for the disinfection of feces and sputum; 
and to a certain extent, for the disinfection of glassAA^are, fabrics, 
brushes, and combs. It is one of the best substances Ave haA^e for the 
general disinfection of rough places, such as slaughter-houses, bake- 
houses, dairies, outhouses, cellars, and the like. In surgery chlorinated 
soda is used, the action of Avhich is entirely analogous to chlorinated 
lime. 


The Stable Fly as a Carrier of Disease. — Schuberg and Kuhn 
(Arbcitcn a. d. Kaiscrl. Ges.-Amt., 1912, xl. No. 2) haAm studied, the 
question of the transmission of various infections, particularly relapsing 
fever, anthrax. Southwest African horse sickness (Pferdesterbe), and 
epithelioma of foAvIs (Hiihnerpocken) through the agency of the 
stable fly (Stomoxijs calcitrans). The first report of these studies AA^as 
published a year ago {Arhciic7i a. d. Kaiscrl. Gcs.-Avit., 1911, xxxi. 
No. 2) Avith special reference to trypanosomes and spirochetes. The 
successful results obtained by Schuberg and Kuhn noAV have an added 
significance in view of the recent findings Avhich incriminate the stable 



HYGIENE AND PUBLIC HEALTH 


155 


£y as a transmitter of the virus of poliomyelitis (Rosenau, Brues, 
Richardson, ct. al., confirmed by Anderson and Frost). _ Schuberg and 
Kuhn successfully transferred the Spirochreta obermeieri from infected 
rats to healthy rats through the bites of Stomoxys calcitrans. Practi- 
cally every one of the flies were able to transfer the infection provided 
only five minutes intervene between the bites of the infected and the 
healthy animal. If ten minutes intervene some of the flies are no 
longer infective, and if fifteen minutes intervene the number of infec- 
tive flies is markedly diminished. It developed, as a result of ten 
experiments, that infection did not occur after an interval of thirty 
minutes. Nattan-Larrier, in 1911, showed that the spirochete of 
relapsing fever may live in the intestinal tract of the ordinary house 
fly that has fed upon infectious material, and pointed out the possi- 
bility of thus transferring the infection. Prior to Nattan-Larrier’ s 
work Sergent and Foley showed that house flies (Musca domestica) 
which fed upon the blood coming from the nose of the patient, contained 
numerous spirochetes which remained intact to microscopic examina- 
tion at least twenty-four hours. Experiments designed to transfer 
the infection from man to apes b^'' means of the common house fly 
were negative. (Other insects, such as body lice, have been incrimi- 
nated as carriers of the infection of relapsing fever.) Copeman, 
Hewlett, and Merriman, in 1911, showed by coloring flies that they 
maj'- By 1700 yards from the place where they are born. It was also 
shown that a fly may travel about one-fourth of a mile in half an 
hour. It is therefore evident that a fly such as Stomoxys dalcitrans, 
wliich is strong upon the wing, may convey the infection of relapsing 
fever for a distance of about 750 feet during the fifteen minutes it 
remains infective. The experimental investigations upon Southwest 
African horse sickness (Pferdesterbe) were likewise successful in that 
this infection was transmitted through the bites of the stable fly. 
Schuberg and Kuhn are careful to note that stall infection is possible, 
and are in some doubt as to how much of a role the Stomoxys plays 
in nature. These same authors made three experiments by interrup- 
ting the bites of Stomoxys in epithelioma of fowls (Hiihnerpocken), 
All three ex-periments were positive. Schuberg and Kuhn express 
the opinion that, in view of the great resistance of this virus, especially 
against drying, and further, in view of the small amount necessary 
to reproduce the disease, it is not unlikely that Stomoxys may remain 
infective a long period of time, and it therefore seems that this may 
be of practical importance in the transmission of the disease in nature. 
The Stomoxys breeds in manure, and it would, therefore, have ready 
access to chickens, which they are known to bite under natural con- 
ditions. Finally, Schuberg and Kuhn succeeded in transferring 
anthrax to mice and guinea-pigs through the bites of Stomoxys calci- 
trans. These experiments consisted in permitting the flies to feed 
upon the livers and spleens of infected animals, and the longest interval 
between such feeding and the bites of the susceptible animal was 
two 'hours and ten minutes. In one case successful infection was 
obtained by the bite of one single fly at an interval of ten minutes. 
Six experiments were then undertaken to transfer the infection from 
animal to animal with one positive result. The donor was a mouse 
having large numbers of anthrax bacilli in its blood at the time of 
e bite; the recipient was a guinea-pig which was bitten ten minutes 



156 


PROGRESS OF iVfEDICAL SCIENCE 


later. It is knoi\Ta that anthrax bacilli appear in the circulating blood 
suddenly, and in nature flies may obtain the infection in this way 
or from shed blood. The latter perhaps would be more dangerous 
on account of spore formation. It is evident that Stomoxys cannot 
play the major role in the transfer of anthrax in nature, but doubtless 
is responsible for occasional case.s, especially anthrax of the skin. 
Man, as well as animals, ma^’' thus receive the infection. 

The Role of the Stable Fly in the Transmission of Surra.' — ^Mitz- 
M. 13. {Plnlip 2 )inc Jouwal of Science, December, 1912, vii, 6 
p. 475) reports the results of a long scries of carefully ' conducted 
experiments to determine the role of Stomox.ys caleitrans in the trans- 
mission of Trypanosoma evansi. Negative results were obtained in 
attempts at direct mechanical transmission of surra with flies, which 
were induced to bite healthy animals at intervals ranging from five 
minutes to three days, after being perinittefl to complete the feeding 
upon infected animals. Thousands of Stomoxys caleitrans were 
employed in twenty-nine experiments, involving the use of three 
horses six monkeys, and twenty-two guinea-pigs. Attempts also 
proved negati^m to transmit surra by the interrupted method of 
feeding. In the.se experiments the intervals between feeding on 
infected and healthj’ animals averaged twenty-five to forty seconds. 
The only positive result obtained was produced from a succession of 
20G interrupted bites, in which the flies were transferred immediately 
from the infected to the “clean” animal. The flies were applied 
thirty-two hours during a period of six days. Mitzmain concludes 
that these experiments indicate that Trypanosoma evansi does not 
develop in the body of Stomoxys caleitrans. He was unable to find 
the organisms of surra in the flies beyond eighteen hours after feeding 
on an infected animal, and the limit for infection by inoculation was 
six hours. Pathogenic trypanosomes were found in tlic proboscis of 
the fly thirty seconds after feeding on infected blood. However, after 
one minute and thirty seconds the organisms were not present in 
the mouth parts in a form capable of infecting by inoculation into 
guinea-pigs. jMitzmain also found as a result of these experiments, 
that the wounds made by Stomoxys caleitrans are not suitable channels 
for infection. No evidence was obtained to indicate that Trypano- 
soma evansi is hereditarily transmitted to the offspring of Stomoxj's 
caleitrans. The larva of this flj'^ fed on surra blood does not continue 
to harbor the trypanosoma, and the fly is “clean” upon reaching 
maturity. Mitzmain believes the the individual glass-tube method 
is the most suitable for applying flies in feeding on experimental 
animals, and for keeping flies for long periods under laboratorj' 
condtions. 


Notice to Contributors. — All communications intended for inserbon in 
the Original Department of this JouKNAL are received only with the distinct 
understanding that they are contributed exclusively to this Journal. _ 

Contributions from abroad written in a foreign language, if on examination 
they are found desirable for this Journal, will be translated ay its expense. 

A limited number of reprints in pamphlet form, if desired, will be furmshed 
to authors, provided the request for them be written on the manuscript. 

All communications should be addressed to tt q a 

Dr. George Morris Piersol, 1927 Chestnut St., Phila., Pa., U. S. A. 



CONTENTS 


ORIGINAL ARTICLES 

Experiences -with Steinmann’s Nail-extension Method in Fractures of the 

Femur 

By John C. A. Geester, M.D., Adjtmct Surgeon to Mount Sinai 
Hospital; Assistant Surgeon to the City (Blackwell’s Island) 
and J. Hood Wright Hospitals, New York. 

The Relations of Internal Secretion to Mental Conditions 186 

By Professor Doctor L. V. Frankl Hochu^art, Professor of 
Nervous Diseases in the University of Vienna, Vienna, Austria. 

An Experimental Study of Sodium Bicarbonate and Other Allied Salts in 

Shock 195 

By M. G. Seelig, M.D., Professor of Surgery, St. Louis University, 
and J. Tiernet and F. Rodenbahgh, St. Louis University. 

Pinching the Appendix in the Diagnosis of Chronic Appendicitis . . 204 

By Anthony Bassler, M.D., Professor of Clinical IMedicine, New 
York Polyclinic Medical School and Hospital; Visiting Physi- 
cian, New York Polyclinic Hospital; Chief Gastro-enterologist, 
German Poliklinik; Visiting Gastro-enterologist, People’s Hos- 
pital, New York. 

The Effects of Continuous Administration of Extract of the Pituitary Gland 208 
By John H. Mhsser, Jr., M.D., Physician to the Medical Dispensary 
of the Hospital of the University of Pennsylvania; Assistant 
Physician to the Philadelphia General Hospital and the Presby- 
terian Hospital, Philadelphia, Pa. 

Tuberculin Therapy in Surgical Tuberculosis, with the Correct Dosage 

Accurately Determined by the Cutaneous Reaction .... 213 
By B. Z. Cashman, M.D., Lafayette, Indiana. 

The Influence on Gastric Secretion of Aseptic Foreign Bodies in the 

Gall-bladder 220 

By 0. H. Perry Pepper, M.D., Associate in Medicine and Research 
Medicine in the University of Pennsylvania, Philadelphia. 

Congenital Bilateral Fistulse of the Lower lip 223 

By L. Miller ICahn, M.D., Adjunct Attending Surgeon, Lebanon 
Hospital, New York. 

A Contribution to the Etiology of Pernicious Anemia 226 

By James Taft Pilcher, M.D., Brooklyn, New York. 

The Role of Hydrotherapy in the Treatment of Pellagra 230 

By George M. Niles, M.D., Professor of Gastro-enterology and 
Therapeutics, Atlanta School of Medicine, Atlanta, Ga. 

TOL. 146, NO. 2. — •AtTGVST, 1913 6 



11 


CONTENTS 


The Analogies of Pellagra and the Mosquito 233 

By Stewakt R. Roberts, S.M., M.D., Professor of Medicine in the 
Atlanta Medical College; Physician to the Wesley Memorial 
Hospital, Atlanta, Georgia. 

An Intensive Study of the Epidemiology of Pellagra. Report of Progress 238 
By Joseph P. Siler, B.S., M.D., Captain, Medical Corps, United 
States Army, and Philip E. Garrison, A.B., M.D., Passed 
Assistant Surgeon, United States Navy. 


REVIEWS 

Manual of Chemistry. A Guide to Lecture.s and Laboratory Work for 
Beginners in Chemistry. A Text-work Specially Adapted for Students 
of Medicine, Pharmacy, and Dentistry. By W. Simon, Ph.D., M.D , 

and Daniel Bare, Ph.D 278 

Surgery, its Principles and Practice, bj’’ Various Authors. Edited by 

William Williams Keen, M.D., LL.D 279 

Text-book of Ophthalmology in the Form of Clinical Lectures. By Dr. 

Paul Roemer, translated by Dr. Matthias Lanckton Foster . . . 281 

Guide to Midwifery. By David Berry Hart, M.D., F.R.C.P.E. . . . 283 

The Surgery of the Stomach. A Handbook of Diagnosis and Treatment. 

By Herbert J. Paterson 284 

Hypnosis and Suggestion. By W. Hilger, M.D., translated by R. W. 

Felkin, M.D., F.R.S.E 283 

The Care of the Skin in Health. By W. Allan Jamieson, M.D 2SG 

Manisch-Depressives und Pcriodischcs Irresein als Erscheinungsform der 

Katatonie. By Dr. Maurycy Urstein 280 

Goulstonian Lectures, 1912; Modem View.s, upon the Significance of Skin 

Eruptions. By H. G. Adamson, M.D., F.R.C.P. (Lond.) . . . 287 

Minor Surgery. By Leonard A. Bidwell, F.R.C.S 288 

Studies in Psychiatry. By Members of the New York P.sychiatrical 

Societj’’ 288 


PROGRESS OF MEDICAL SCIENCE 

MEDICINE 


under the charge of 


W. S. THAYER, M.D., and ROGER S. MORRIS, M.D. 


Primary Splenomegaly (Gaucher Type) 

Renal Diabetes during Pregnancy 

Edema of the Lower Part of the Esophagus from Vomiting .... 
Experimental Observations on the Influence of Venesections and Intra- 
peritoneal Blood Injections on the Number and Resistance of Red 

Blood Corpuscles 

On the Relation of Eosinophilia to Anaphjdaxis 

Observations in Two Cases of Pentosuria 


289 

290 
290 


290 

291 
291 



CONTENTS 


111 


On the Production of the so-called “ZeUschollen” in Lymphatic Leukemia 
Disturbances in the Hydrochloric Secretion in Diseases of and following 

Extirpation of the Gall-bladder 

Calcium Metastases and Calcium Gout . . . ■ 

A Method of Differentiating between Ascites and Fluids from Ovarian 

Cysts 


292 

292 

293 

293 


SURGERY 

DNOER THE CHARGE OF 

J. WILLIAM WHITE, M.D., and T. TURNER THOMAS, M.D. 


The Radical Operation for Cancer of the Uterus 294 

Results after the Wertheim Operation for Carcinoma of the Cervix of the 

Uterus 2,94 

The Treatment of Beginning Gangrene 295 

The Diagnosis and Treatment of Gangrene of the Foot 296 

The Treatment of Beginning Gangrene 296 

The Treatment of the Pyelotomy Wound 296 

The Etiology, Symptomatology, and Pathogenesis of Acute Intestinal 

Obstruction 297 


THERAPEUTICS 

ONDER THE CHARGE OF 


SAMUEL W. LAMBERT, M.D. 


Whooping Cough. Its Treatment with Vaccine 

The Vaccine Treatment of Whooping Cough 

The Effect on the Nervous System of Healthy Rabbits of Large Doses of 

Salvarsan 

Neosalvarsan 

Mercury and Salvarsan 

Trivahn 

Adigan, a New Digitalis Preparation 

The Value of the Karell Diet 

The Treatment of Vincent’s Angina 

The Treatment of Local Spirochete Infections by Salvarsan and 
■Neosalvarsan 


298 

298 

299 
299 
299 

299 

300 
300 
300 

300 


PEDIATRICS 

UNDER THE CHARGE OF 

LOUIS STARR, M.D., and THOMPSON S. WESTCOTT, M.D. 

The Treatment of Scarlet Fever with Neosalvarsan 

The Btiologj- of Measles • 

The Cause and Prevention of Adenoid Growths in Children 



IV 


CONTENTS 


OBSTETRICS 

UOT)BH THE CHAIIQB OF 

EDWARD P. DAVIS, A.M., M.D. 

Hebostiotomy 

The Influence of the X-rays upon the Membranes 303 

Hematoma of the Abdominal Wall in Pregnancy 303 

The Electrocardiogram in Pregnancy 303 

Uterus Bicorm's Causing Chronic Transverse Position of the Fetus . . 303 

The Correlation of the Internal Secretions of the Ductless Glands and the 

Genital Functions of Women 303 

' The Ovary as an Organ of Internal Secretion 304 

The Mucous Channels and the Blood Stream as Alternative Routes of 

Infection 304 

GYNECOLOGY 

UNDER THE CHARGE OF 

JOHN G. CLARK, M.D. 

Treatment of Postoperative Retention of Urine 305 

Treatment of Uterine Hemorrhage by the X-ray 305 

The Use and Abuse of the Curette 306 

OTOLOGY 

UNDER THE CHARGE OF 

CLARENCE J. BLAICE, xM.D. 

The Function of the Auricle 207 

The Relationship between the Hearing for the Whisper and the Conversa- 
tional Tone 208 

Clinical Observations upon a Hitherto Undescribed Form of Tuberculosis 

of the Middle Ear 209 

Temporary GIj'cosuria in the Course of Suppurative Middle Ear Disease 309 


PATHOLOGY AND BACTERIOLOGY 

UNDER THE CHARGE OF 

JOHN McCRAE, M.D., M.R.C.P. 

The Bordet-Gengou Bacillus of Whooping Cough 310 

The Effect of the Spleen and Splenic Extract upon Malignant Tumors . 310 

Anaphylotoxine, Peptotoxine, and Anaphylaxis 211 


THE 


AMEEICAN JOTJENAL 

OF THE MEDICAL SCIENCES 

AUGUST, 1913 

OIUGINAL ARTICLES 

EXPERIENCES WITH STEINMANN’S NAIL-EXTENSION METHOD 
IN FRACTURES OP THE FEMUR.^ 

• By John C. A. Gekster, M.D., 

adjdnct snnGEON to mount SINAI hospital; assistant bubgeon to the ciTr (biacktvell’s 
island) and J. hood WRIGHT HOSPITALS, NEW YORK. 

The essential part of Steinmann’s^ method consists of a nail 
which transfixes the soft parts and bone, and which is the sole 
point of attachment for suitable traction upon the lower fragment. 
In other, words, the bone and soft parts are transfixed by a drill 
which is left in place with both its ends projecting. 

Apparatus. The steel nail is 3| mm, thick, 18 to 20 cm. (7 to 
8 inches) long; the ends should project 2| to 3 cm. beyond the 
skin (Fig. 1). The nail may be driven through the bone either 
by a simple handle resembling a clock key, or by a bit and brace, 
or by a geared hand drill (Fig. 2). An adjustable pair of tongs 
(Fig. 3), the limbs of which are joined by a suitable thumbscrew, 
forms the most convenient means of attaching extension apparatus 
to the nail ends. 

In describing the typical procedure, let us take, for example, 
the treatment of a fracture of the femoral shaft at its middle third. 
The sterilized nail and drilling mechanism are fitted together 
and placed in readiness. The entire limb is brought close to the 
margin of the table or bed, so as to prevent interference wuth the 
drilling that is to follow. One assistant grasps the patient’s ankle 
and, maintaining traction, elevates the leg, while the operator 
who is ''sterile” applies full-strength tincture of iodine to the skin 
and does the necessary draping. The leg is then lowered, so that 

' Read before the Surgical Section of the New Yorlc Acadomy of Medicine, January 3, 1913 . 

" Nagel extension der Knoche bruche, Neue Deutsche Chirurgie, 1912, Band i; British Med. 
Jour., November 30, 1912, p. 1235, 

VOL, 140, NO. 2. — AUGUST, 1913 



iob gerster; steinjmann’s nail-extension jiethod 

ankle and knee are close to the edge of the table. Another assis- 
tant h^nng sterilized himself, assumes management of the broken 
li™ 7 - L / anesthesia (gas) is now started. The assistant steadies 
the iiinb (outer margin of the foot must stay vertical), at the 
same time pulling the skin of the thigh upward. The point of the 
nail is inserted horizontally and at right angles to the shaft a iinger’s- 
breadth above the upper margin of the external condyle. As soon 



Fig. 1. — Solid nails of varj'inp: Icncths. The points arc sharpened on four sides; the heads 
are round in order to fit the chuck of the hand drill. 



Fig. 2 . — Geared hand drill. 

as the bone is touched, drilling is begun (Fig. 4). The operator 
controls the drill with both hands and leans Ins body, either chest 
or groin, against the breast-piece of the drill. The resistance ndiich 
at first is encountered, lessens after a while, for penetration is 
easier after the corticalis is passed, as the cancellous tissue offers 
less resistance. Again, progress is slower as the corticalis of the 
opposite side is encountered. Finally, this also is passed and 


gerster: steinmann’s nail-extension method lov 

the nail point may be felt emerging from the bone. 
overlying^the nail point is pulled upward by the assistant and the 






Li 



Fig. 3. — Tongs with nails, solid and two piece, and handle. 




Fig. 4. — Transfixing the lower end of the femur. (Stoinmnnn.) 






160 GERSTER: STEINM Ann’s nail-extension method 

point finally emerges. Drilling is stopped when the two nail ends 
project equally on either side of the limb. The narcosis is then 
stopped. The skin which the penetrating nail point has carried 
away from the leg is now pushed back on the nail to the level of 
the adjacent skin. Tincture of iodine, then aristol, and lastly 
collodion are applied to the skin where the nail emerges. Small 
flat pieces of folded gauze are transfixed by the nail points and run 
down the nail shaft to the skin.^ A figure-of-eight bandage holds 
them in place; it is well for some turns of the bandage to be 
transfixed by the nail points. 



Fio. 5. — Case VI. Nail in supracondylar position. Note wiro lastened to ends of 

crossed limbs. 


The extension apparatus is now attached to the nail. The 
two limbs of the tongs are applied so that the thumbscrew holding 
them comes uppermost — each limb is applied separately — the 
screw being inserted in that hole of either limb which most readily 
falls in alignment. The ends of a short piece of wire are fastened 
through the outermost holes of the crossed limbs of the tongs 
(Fig. 5). At the centre of this wire is attached the main traction 
wire or rope leading over a pulley at the foot of the bed down to 
the suspended weights. The thigh is placed in semiflexion. The 
leg is horizontal or the foot may be lower than the knee. The heel 
should not touch the bed. Hard pillows, sandbags, or suitable 
splints may be employed to maintain this position. The pulley 

» Another nail may be used to make holes in the gauze, bo that it readily slips over the rounded 
head of the nail Tvhich is in place. 



gersI'Er: steiotiann’s nail-extension method 161 


at the foot of the bed must be placed so that the wire leading from 
the tongs is in line with the axis of the semiflexed thigh (Fig. 6). 



Fig. 6. — Case V. Note traction wire in line with axis of thigh, also suspension of outer 
end of nail_to_prevent eversion (rotary displacement). 




Naturally the amount of weight to be used depends 
upon the individual case. In a recent fracture of an 
adult femur, with 5 cm. shortening, 18 to 20 pounds 
are usually adequate. It is very convenient to use 
a small spring scales registering up to 40 pounds, 
to ascertain how much weight is being applied 
(Fig. 7). 

Countertraction may be obtained by (a) raising 
the foot of the bed; (b) a well-padded perineal loop 
attached to the head of the bed, and (c) a foot-rest 
for the sound limb. 

Shortening is usually overcome within a week. 

The broken limb should be allowed to stretch 1 cm. 
longer than its fellow. This renders proper approx- 
imation of the fragments easier. In transverse frac- 
tures, after proper reduction, overcorrection is no 
longer necessary, while in oblique fractures it is well 
to maintain | or 1 cm. overcorrection until union takes 
place.^ After the shortening has been overcome, less 
weight is required to maintain the fragments in proper fw ? —scales 
position. Undue lengthening is readily corrected by 
simply lessening the weight— the limb promptly shortens. Massage 
and passive motion may be begun five days after nail-extension 



162 


gerstee: steinmaiwj’s nail-extension method 

lias been instituted. A good callus is usually developed by the 
end of three weeks. Steinniann states that, if possible, nail- 
extension should not be maintained longer than three weeks, 
and never longer than five weeks. Thirty-four days is the longest 
time I have personally seen the nail-extension maintained. 

At the end of three or four weeks there is usually sufficient 
callus to justify removal of the nail. If the nail is solid the end 
which is to be drawn through is exposed, it and the adjacent 
sldn are carefully cleansed with tincture of iodine, which is applied 
most thoroughly, after this the nail is withdrawn. The rounded 
head is firmly grasped by a heavy pair of wire pliers. The nail is 
first rotated to loosen it and is then extracted with a rotary motion. 
The knee should be steadied by an assistant. Under gas the 
actual extraction takes less than one minute. If the nail is in two 
pieces, the two halves are unscrewed and pulled out, each on its 
own side. Some tincture of iodine is injected into the nail holes 
and a wet dressing is applied until the skin is healed, usually within 
• five or six days. 

J\Iost of my cases ran a slightly elei’^ated temperature, between 
99° and 100°, while the nail was in place; this dropped again upon 
removal of the nail. There were no signs of infection. 

The subsequent treatment is that appropriate for any limb with 
a fresh callus — namely, avoidance of too much strain on the 
callus, at the same time employment of suitable passive and active 
motion. 

I. Details of Treatment. A. Location of the Nail. According 
to Steinmann (1) it should avoid the hematoma at the site of 
fracture; (2) it should avoid the marrow cavity;® (3) it should 
avoid the joint capsule; and (4) it should avoid the epiphyseal line. 
Hence the nail is inserted one finger’s breadth above the upper 
margin of the femoral condyle just behind the middle line of 
the bone — in other words, through the posterior half of the supra- 
condylar region just anterior to the adductor tubercle or its 
corresponding site externally. 

In fractures of the lower third of the femur the nail is inserted 
through the upper end of the tibia 2| fingers’ breadth below’ the 
upper margin of the tibia on a level with the lower margin of the 
head of the fibula (Fig. 8). 

B. Methods of Inserting the Nail. (1) Hammering has been 
found to cause too much pain at the site of fracture — the risk of 
splintering the bone is not great.® (2) Boring by hand is safer than 

» At the point where the nail passes through the bone, there is enough cancellous tissue to 
prevent direct communication with the main marrow cavity. 

6 In a recent case of Dr. William H. Bishop’s it was impossible to insert the nail by hand 
drilling because of the extreme hardness of the femur. The patient was a woman, aged fifty 
years, with a fracture of the upper third of the bone. A hammer was not available at the 
time, so the attempt to insert the nail had to be given up- At the subsequent plating the 
bone was found to be just as hard at the site of fracture, as it was near the condyles. The 
corticaljs was very thick and there was cancellous tissue in the marrow cavity. 



GrfillS'iElS.'. STEINMANN^S NAIL— EXTENSION METHOD 163 

by electricity. (3) Incision of the soft parts is unnecessary and 
increases the likelihood of infection. Other modifications of the 
method, such as boring a hole and then inserting the nail, etc., 
can be placed in the same, category. (4) It is necessary to pull 
the skin proximally, especially in supracondylar insertion or 
the nail, because if this is not done, as the limb is stretched, 
decubitus of the skin will occur to the distal side of the nail. 



Fig. 8. — Positions for insertion of nails through femur and tibia. 

C. Type of Nail. The two-piece nail apparently cannot be 
made of sufficient strength to afford a proper factor of safety 
against breakage at its joint. The nail has broken six out of the 
sixteen times I have used it. The weights used were never more 
than 20 pounds, usually about 15 pounds. Fortunately, when the 
tongs were used the broken nails were held in sufficiently good 
position to still maintain traction (Fig. 37). Breaking has occurred 
during insertion, during transport of the patient in bed to the 
.r-ray room, and with the patient lying quietly in bed as late as 
the eighteenth day._ I therefore prefer solid nails. Both head 
and point of the original nails are squared. They do not accurately 
fit the ordinary hand drill with a three-point contact chuck, hence 
I use nails with round heads which fit the usual types of drill 
(Fig. 2). 

D. Dressing. Dressing should be dry and rather voluminous. 
The details have alreadj'^ been given. 



164 gerster: steiniviann's nail-extension method 

E. Attachment of Traction. The tongs are most convenient for 
this purpose, but they are not essential. Braided picture wire, 
copper wire, or bandages (Figs. 9 and 14), may be used. In this 
case the ends of the nail are protected by corlcs. Spreaders may 
be necessary to prevent undue pressure of the wire against the skin 
in some instances, while in others an S-hook or wire loop may be 
required to prevent the end of the traction wire from slipping off 
a nail end. Where tongs are used the traction should be made 
upon the ends of the crossed limbs, not at the point where they, 
cross (Fig. 6). 



Fig. 0. — Case II. Pertrochanteric fracture. Tongs were not available, so bandages were 
* fastened to the nail ends. Note small sandbag parallel to limb which supports the outer end of 
nail, thus preventing eversion. 

F. Anesthesia. There may be a short general anesthesia, either 
laughing-gas or “aether rausch,” or, there may be a local anesthesia 
(0.5 per cent, cocaine) in the cases where the former is contra- 
indicated. In intelligent adults it is possible to do without an 
anesthetic, for the pain of the boring is by no means unbearable 
(see Case VII). Indeed, most of the pain felt is at the site of 
fracture. 

G. Amount of Weight. In recent fractures this varies between 
10 and 30 pounds; in old fractures between 20 and 60 pounds. 
Steinmann speaks of one case where an old fracture with mal- 
union was refractured, nail-extension was applied, and a lengthen- 
ing of 11 cm, was obtained within eight days. As said before, 
most of the stretching is done in the first week, after which much 
less weight suffices to maintain proper position, 

H. Control of Fragments. The direction of the pull can be varied 
to adapt the lower to the upper fragment. Strong traetion often 



gerster; steinmajot’s nail— extension method Ibb 

causes tlie upper fragment to f bllow the lower to a great extent 
that is, lateral dislocation is corrected largely by extension alone 
(see Case VI). 



Fig. 10. — N’aii-oxtonsion applied to head of tibia. (Steinmann.) 



Fig. 11. — Nail-extension, with anterior pull at right angles to limb. (U^aegner.) 

Postevior dislocatioJi of the lower fragment in supracondylar 
fractures is knoum to be especially difficult of correction. Flexion 
of the leg upon the thigh and dorsal flexion of the foot upon the 
leg lessens the pull of the gastrocnemii upon the lower femoral 
fragment which is displaced backward. Traction at right angles to 
the leg also aids in correction of this condition (Figs. 10 and 11). 




166 gerstek: steinmann’s nail— extension method 

Rotary displacement (eversion) is best corrected by suspension 
of one nail end. This is most conveniently accomplished by two 
uprights and a horizontal bar running the length of the bed, with 
a wdre attached to the lateral (outer) end of the nail and to the 
horizontal bar (Fig. 7). In fact, the entire limb may be most 
conveniently suspended by this simple means. 

It is unnecessary to review all the modifications and varieties 
of lateral traction and suspension w'hich have been employed in 
other extension methods, notably in that of Bardenheuer. It 
goes wdthout saying that they have been employed in the Stein- 
mann method since 1907 with even better chances of success. 

If possible, .T-ray plates should be made before extension is 
applied; afterward controls can be made at proper intervals to 
make sure of proper position. As a matter of course the exposures 
should be made both from in front and from the side. Portable 
.T-ray outfits are becoming quite common. With one of these 
exposures can be made without disturbing the limb. In hospitals 
wdthout portable z-vay apparatus, a bed-truck may be used to 
transport the patient in bed into the x-ray room. A physician 
should accompany the patient upon this journey. The personal 
supervision of transport by one wdio understnds the rationale of 
the apparatus wdll prevent unnecessary pain to the patient and 
undue strain upon the apparatus. As said elsew^here, jarring by 
rather light weights (15 pounds) during transport has been suffi- 
cient to break the twm-piece nail at the joint. 

Even wffien the .r-rays are not available, very fair results can be 
obtained by careful daily control with tape measure and fingers. 
While measurement is being made, the sound limb must be flexed 
to the same degree as the fractured one. It is well to measure from 
a number of points for the sake of control, for example, from the. 
anterior spine to the nail, as well as to the internal malleolus. 



Fig. 12. — Splint for maintaining extension during transport to the x-ray room. (Stemmann . ) 

Steinmann has devised a sort of hip splint wffiich can be adjusted 
so that its upper margin rests against the pelvis, and its lower 
margin impinges upon the projecting nail ends; it thus prevents 
shortening wdien traction is taken off. This splint was designed to 
facilitate the transport of patients to some place wffiere an a:-ray 



gerster: steinmann’s nail-extension method 


exposure can be made (Fig. 12). From what I have seen, the 
less a patient is moved after extension is once applied, the better . 

II. Objections Which Have Been Made Regarding Stein- 
mann’s Method. A. Pain. (1) Upon introduction of the nail 
an anesthetic is usually employed, yet under unusual circumstances 
it may be dispensed with (see Case VII). (2) During extension 
no pain is felt at the site of the nail. If traction is irksome the 
weights may be lessened for a few hours and then added again. 
(3) At removal of the nail there may be slight pain. By this time 
the nail is loose in the bone except when lodged in the head of the 
tibia, from which its extraction may require considerable force. 
It is well not to allow children or excitable adults to know that 
a nail is being employed. As long as they are ignorant of its 
presence they do not complain. A voluminous dressing applied to 
the leg satisfactorily conceals things. 

B. Infection occurs either at the time of insertion or after two 
or three weeks. It is easy to insert the nail aseptically, but it is 
difficult to keep the region aseptic in the later stages. The granu- 
lations which have formed by the end of three weeks afford a 
fairly good protection to the bone at large. Small local infections 
have been known to occur, especially iii long-continued cases of 
extension. These have all remained localized. Small circular 
sequestrse have come away. A small exostosis occasionally develops 
at the site of the nail. So far there has been no mortality from 
nail-extension — carried out according to the rules laid down by 
Steinmann. Fatal cases are known where the wound made by the 
nail has established communication with the fracture hematoma, 
thus converting a simple into a compound fracture. 

C. Injury by the nail to important nervous, vascular or articu- 
lar structures. There has been none at the time of insertion. 
Steinmann even reports a case where the nail had been run through 
the ankle-joint without causing any functional trouble. 

The epiphysis has not been harmed, as shown by four years’ 
observations upon ehildren on whom this method had been em- 
ployed. There was no lessened growth of the injured side. 

D. Injury by too great traction has been ascribed to nail extension. 
There has been no instance of harm to the soft parts. An ex- 
treme example of what can be accomplished is shown by the case 
of Steinmann’s, where 11 cm. lenghtening was obtained within 
seven days in a refractured malunion of five or six months’ 
standing. There was no loss of function. 

E. Lax Knee-joint. ^ Strong diversity of opinion exists regarding 
injury to the knee-joint by traction (such as Buck’s extension) 
applied to the limb below the knee. Naturally this controversy 
will promptly'' transfer itself to application of the Steinmann method 
m fractures of the lower third of the thigh where the nail is inserted 
through the head of the tibia; hence, a brief outline of the situation 
seems proper here. 



168 


GERSTER: STEimiANN’S NAIL-EXTENSION METHOD 

Certain observers emphatically state that they have observed 
the most harmful effect upon the knee-joint from extension applied 
to the leg below the Imee. Other equally competent authorities 
maintain that they have never seen any injury to the knee-joint 
from application of Buck’s extension to the leg as well as the thigh, 
and furthermore insist that no adequate extension can be obtained 
by merely pulling on the skin of the thigh. 

It is to be noted that Steinmann’s method differs from Buck’s 
extension in that the knee-joint is flexed, whereas in Buck’s ex- 
tension the knee-joint is fully extended. Perhaps there is less 
strain upon the ligaments when traction is applied to the partially 
flexed joint than when there is full extension. My own experience 
in this matter is not sufficiently extensive to be of much value. 
Steinmann states that he has never seen any distraction of the 
knee-joint from trabtion upon the tibia. He also states that 
effusions into the joint disappear with great rapidity after extension 
is made; this likewise has been my own experience. The transient 
inability fully to extend the knee rapidly disappears under appro- 
priate massage and passive motion. 

F. Delayed Union. None has been observed so far. On the 
contrary, Steinmann says that firm union is usually obtained in 
seven or eight weeks, in some cases even as early as five weeks. 
The fact that both passive motion and massage can be employed 
while extension is going on certainly has much to do with prompt 
callus formation and union. No pseudartliroses have occurred. 

III. Advantages. A, Traction. Less weight is needed for any 
given case than by other methods. More weight can be used than 
by any other method, and this without the risk of decubitus. The 
traction is continuous, not spasmodic, as in Codivilla’s method or 
in Lane plating. In cases of long-standing malunion the soft 
parts may be so contracted that, after freeing their ends, the bones 
cannot be placed end-to-end without undue tension upon the 
soft parts which may cause cessation of circulation in the distal 
part of the extremity or even rupture of important structures. 
It is in such cases that the continuous traction safely accomplishes 
its purpose in from three to five days. 

B, Painlessness. Once the nail is in position there is no pain 
due to its presence. In fact, after a few days the patients are apt 
to become careless because of their freedom from pain, 

C, Control of the fragments, especially of the lower one, is more 
certain by this method than by any other except the open operation. 

D, The small site of attachment makes the method available 

in the compound fractures where other traction methods are either 
difficult or impossible of application. ^ . . . „ , 

Simplicity and possibility of improvisation are qualities of the 
method which cannot be too strongly praised. Steel drills and the 
apparatus for driving them, or long nails, together with some 



gerster; steinmann’s nail— extension method 


wire or stout cord, are obtainable almost anywhere, and they can 
be made to serve one’s purpose. 

The value of the method in military or naval senvce or in 
inaccessible regions, is readily apparent. The Prussian army uses 
it. It is time-saving, effective, and easily learned. 

Comparison of Results. With Buck’s extension we have more 
or less shortening and stiffness of the knee, which lasts for a long 
time afterward. With the Steinmann method there is no short- 
ening, and the transient inability fully to extend the knee-joint 
quickly disappears. In some cases it is never present. 

With Lane plating we have the risk of grave infection if the 
operation be done by any except the skilled, and in any case, 
somewhat delayed union. In certain exceptional cases even with 
no infection, union may be delayed for months, and long im- 
mobilization of the knee-joint in such cases has resulted in what 
amounts to an ankylosis. With the Steinmann method there is 
much less risk of infection (there have been no fatal cases so far) ; 
there is no delayed union (in the average case), and the joints 
have little, if any, impaired function. 

The method of Ransohoff,® whereby the point of a pair of ice- 
tongs are lightly driven into the bone, is a recent modification of 
the same principles governing nail extension. The site of attach- 
ment with tongs is larger than with the nail. 

IV. Indications for Using Nail Extension. A. Recent 
Fractures. Fractures of the femoral neck constitute debatable 
ground. Impacted fractures of the neck against the head had 
better be left alone. Intracapsular fractures in the young show 
brilliant results when spiked in their proper position at opera- 
tion. Where operation is contraindicated, Whitmann’s abduc- 
tion is the most rational method for properly approximating 
the fragments. Pertrochanteric fractures, on the other hand, give 
excellent results with nail extension (Cases II and V). 

In fractures of the shaft, in very obese individuals where adhesive 
plaster is not effective, nail-extension is indicated (Case VII). 

In supracondylar fractures it affords better control of the lower 
fragment than any other traction method. 

In short, nail extension is indicated wherever the usual traction 
methods fail. A case of von Eiselsberg’s, quoted by Steinmann, 
illustrates this. In a fresh fracture of the lower third of the femur 
it was found that there was such pressure upon the popliteal 
artery that the pulse was obliterated. Traction by the usual 
adhesive plaster did no good. Nail extension was then resorted 
to and the pulse returned. 

B. Old Fractures.^ This is a field which has been practically 
untouched by traction methods.. The fact that nail-extension can 


® Lancet-Clinic, August 17, 1912. 



170 


gerster: steinmann’s nail-extension jiethod 


be employed with success at a considerable time after the fracture 
has occurred, makes it of value when a fracture is complicated 
by extensive abrasions of the skin or by acute disease, such as 
delirium tremens or pneumonia. Here one can wait until recovery 
has taken place before applying extension. The method has been 
successfully used in fractures of forty days’ standing in which usual 
traction methods have been of no avail. 

In malunion with much overriding, operation followed by the 
Steinmann method is the only way in which an ideal result can 
safely be obtained. The malunion is broken up, and afterward 
nail-extension is applied. Naturally, larger weights (up to 60 
pounds) must be employed. This procedure has been used as late 
as three to six months’ after malunion had taken place. 

In pseudarthroses, rubbing of the bone ends together, followed 
by application of extension, has been suggested. When this is 
not sufficient the bone ends may be cut down upon and freshened, 
the wound then closed and nail-extension applied. 

As a preliminary to Lane plating in cases where that method 
is indicated (interposition of soft parts, etc.) nail-extension is 
excellent, because the absence of shortening lightens the operator’s 
task fully 75 per cent. 

To conclude, in certain cases nail-extension is the only method 
to be used, in others it is an aid to previously existing methods. 

I take the opportunity of e.xpressing my gratitude to Drs. Howard 
Collins, William H. Bishop, A. G. Gerster, John A. Wyeth, Seth 
Milliken, and Ernest Fahnestock for their kindness in allowing 
me to employ this method in their services and for the privilege 
of publishing their cases, the abstracts of which follow (Cases I, 
II, HI, V, VI, Vn, IX, and X were presented at the time this 
paper was read). 

SYNOPSIS OF CASES. 

Case I. James L., aged four and one-half years (Dr. Howard 
Collins’ service. City Hospital, Blackwell’s Island). 

June 26, 1912. "A board fell from a building and struck the 
patient, causing an oblique fracture of the middle third of the left 
femur. Admitted to City Hospital on June 27. 

July 2. Sixth day after fracture. Steinmann two-piece nail; 
supracondylar insertion. Laughing-gas anesthesia; 6 pounds trac- 
tion; 1 cm. shortening. 

Jub”^ 9. I cm. overcorrection; 4 pounds traction. 

July 22. I cm. overcorrection. 

July 23. Twenty-first day. Nail removed. (X-ray, Fig. 13.) 

July 25. Limbs equal ; nail holes clean. 

August 3. Child can raise entire limb to vertical position; flex 
and extend knee. Nail holes, two small clean, granulating spots. 

October 5. Function perfect; runs and walks without a limp. 



gerster: steinmann’s nail-extension method 171 

Evicrisis. This was a restless, active child who had no pain 
after the first three days, and who had to be restrained by loops 
of bandage at the anlde, knee, hip, and armpit in order to maintain 
proper alignment of fragments (Fig. 14). - 



Fig, 13. — Case I. Plate taken twenty-one days after fracture; no shortening. 



I' 10 . 14. Case I. Illustrating restraint necessarj’' with active children to maintain proper 

alignment of fragment. 


Case II. James R., aged sixty-five years (Dr. Howard Collins’ 
service. City Hospital, Blackwell’s Island). 

June 14, 1912. Admitted to Bellevue Hospital with a fracture 
of the neck of the femur. 



172 GETtSTER: STEINMANN^S NAIIr-EXTENSION METHOD 

June 21. Transferred to the City Hospital, with a shortening 
of If inches and marked eversion. 

June 22. Buck’s extension with 10 pounds traction applied. 

July 1. Sixteenth day after fracture 3 cm. shortening. Stein- 
mann two-piece nail; supracondylar insertion under laughing gas: 
21 pounds traction (Fig. 11). 

July 12. f cm. shortening. 

July 18. Eighteenth day after insertion. Nail broke at joint; 
inner half loose and removed; wet dressing applied to nail hole. 
Outer half was solid (Fig. 13), and sandbag, which had been 
placed underneath its end to prevent eversion, and to maintain 
the limb in proper position, was left undisturbed. 

July 19. 1 cm. shortening; .r-ray plate (Fig. 15). 



• Fjg. 15. — Case II. Pertrochanteric fracture Fig. 16. — Case II. The same five months 

nineteen days aftqr extension applied. later. , 

July 23. Outer half of nail removed. 

July 27. Nail holes healed; good union; massive callus. 

July 29. 2 cm. shortening; patient comfortable. 

August 14. Patient is encouraged to sit up and to try to walk 
on crutches. 

August 28. Shortening nearly 3 cm. ; good flexion and extension; 
some limitation to inward rotation. Edema of right leg and anide, 
which has existed since patient was out of bed on crutches, grad- 
ually subsiding under massage. 

December 1. Patient has been on crutches for the past three 
months. Has now been encouraged to walk. 

December 23. Bad dermatitis of right leg and ankle from undue 
use of chloroform liniment. 



gerster: steinmann’s naie-extension method 173 

December 30. X-rays (Fig. 16) show neck joined to the shaft 
at more of a right angle than previous picture; firm union. 

Epicrisis. The nail broke on the eighteenth day. Traction was 
being made by bandages fastened to the projecting ends of the nail. 
No tongs were available at that time, and it was not feasible to 
apply other methods of traction. Had extension been maintained 
for a week longer, it is probable that no shortening would have 
ensued after removal of traction. Where the two-piece nail has 
broken with the tongs grasping its ends it has been found possible 
to still maintain traction, since the tongs hold the fragments of the 
nail at approximately right angles (see Case XII). 

Case III. — ^Mary H., aged seven years (Dr. Howard Collins’ 
service, City Hospital, Blackwell’s Island). 

August 24, 1912. Fell three stories to the ground from a fire- 
escape, striking a shutter, and other fire-escapes on her way down, 
sustaining a fracture of the lower third of the right femur. A 
projecting fragment could be felt in the popliteal space. There was 
no obstruction to the circulation; 3 cm. shortening. 



Fig. 17. — Case III. Supracondylar fracture before reduction. 


August 26. Second day after fracture. Under laughing-gas 
anesthesia. A two-piece nail driven through the head of the tibia; 
8 pounds traction. 

August 28. i cm. shortening. 

September 3. X-rays show lower fragment displaced outward 
(Fig. 17). 

September 9. Reduction of fragment under laughing-gas, by 
Dr. A. L. Sherman. 

September 19. Twenty-fourth day, nail removed. 



1<'4 gerster: steinmann’s nail-extension method 

September 26. Excellent union; patient can raise heel from 
bed, flex the leg completely, and extend it to within a few degrees 
of full extension. 

October 10. A"-rays (Figs. 18 and 19) show excellent position. 

October 18. Out of bed for the past few days; can now fully 
extend leg; limps less and less as time goes on. 

October 19. Discharged from hospital. 

November 14. Some effusion of knee-joint, which the mother 
says has been present since leaving the hospital. Limp barely 
perceptible. 



Fic. IS. — Case III. Both knees after reduction. Fjo. 10. — Case III. Final result. 


December 24. Effusion of knee gone; walks and runs with 
perfect freedom. 

Epicrisis. There was union within one month. Slight limitation 
to full extension, which was present for a time after removal of 
the nail, gradually disappeared. The effusion of the knee-joint 
was present for five or six weeks after discharge from the hospital, 
and subsided without treatment. 

Case IV. — John H., aged eighteen years (Dr. Howard Collins’ 
service. City Hospital, Blackwell’s Island). 

September 30, 1912. Was hit by an automobile mud-guard 
while roller-skating in the street. He was knocked senseless, and 
sustained a fracture of the middle third of the left thigh. 

October 1. A large effusion of the knee-joint. Shortening 
about 4 cm. 

October 3. Fourth day after fracture, Steinmann’s two-piece 
nail inserted through the head of the tibia; 10 pounds traction. 




gerster: steinmann’s nail^extension method 175 

October 5. Shortening 2.5 cm.; 18 pounds traction. Effusion 
of the knee-joint gone. 

October 10. 1 cm. over correction. 

October 23. Twenty-first da3^ Nail removed. Some force 
necessary because of its firm fixation in the tibia. 

October 25. Plaster spica applied, reaching to the hip. At 
this time there was slight lateral mobility, considerable callus, 
and it seemed as though the upper fragment had moved anttyiorly. 
There was slight lateral mobility of the knee-joint; no limitation 
to passive motion of the knee-joint. 


Fig. 20 


Fig. 21 



Fig. 20. — Case IV. Transverse fracture seen from in front. 

Fig. 21. — Case IV. The same seen from the side. The plate taken at the same time as Fig- 20. 
was lost, but it showed the same position as this plate (Fig. 21), which, together with Fig. 22 
was taken two months later. 


October 31. A^-rays (anteroposterior view) show good position 
(Fig. 20). Lateral view (Fig. 21) shows overriding of transverse 
fragments. This was the first time this case had been .T-rayed. 

November 6. Cast removed. Up in rolling-chair. 

November 15. Patient slipped getting into chair and fell on 
the floor. 

November 17. There was marked bowing and 2| to 3 cm. 
shortening. Supracondylar insertion of nail was suggested as the 
best available traction. This was refused by patient. Because of 
this, Buck’s extension (15 pounds) and lateral traction (15 pounds) 
at the greatest prominence of the bowing were applied. 

November 26. Bowing of thigh has gone; lateral traction 
discontinued. 



176 


gerster: steinjiann’s NAI]>-EXTENSI0N method 


December 1. Buck’s extension discontinued; 1 cm. shortening 
present at this time. 

December 22. ^ Patient has Iain quietly in bed the past three 
weeks, ^ the leg being in the same position that it Was while Buck’s 
extension was being maintained. . There was 2 cm. shortening. 
Flexion beyond 60 degrees limited. Full extension. Some effusion 
of Icnee-joint ever since discontinuance of Buck’s extension. 

December 24. A^-rays show good callus and slight overriding 
of the fragments (Figs. 21 and 22). There is no angulation of the 
thigh. 



Fig. 22. — Case IV. Front view two months later than Fig. 20. 

/ 

December 30. Home on crutches, with a perfectly solid union, 
Epicrisis. There were no facilities for controlling treatment by the 
rc-rays. Because of the extensive effusion of the Icnee-joint and 
because of the contusions of the thigh, it was deemed wiser to apply 
traction to the bead of the tibia rather than to run the risk of possibly 
infecting a hematoma of the thigh. A better result might have 
been obtained had a solid nail been used in the supracondylar 
region and had it been possible to follow effects of traction with the 
.r-rays. It seemed unwise to use more than 20 pounds weight 
with traction on the head of the tibia. _ • ^ 

Case V. — John M., aged thirty years (Dr. William H. Bishops 
service. Flower Hospital, New York.) 

October 10, 1912. Fractured neck of femur while trying to stop 
a runaway. His foot slipped and the wheel struck him, knocking 
him down. An .T-ray plate taken at the time showed an extra- 
capsular fracture passing through and below the greater trochanter. 



GERSTEIi: STEINMANn’s NAIL-EXTENSION METSOE 177 

Unfortunately this plate was lost. There was a shortening of 
1| inches (3.5 cm.). 

October 14. Fourth day after fracture, under gas and oxygen; 
two-piece nail; supracondylar insertion; 15 pounds traction; 
external rotation prevented by suspending the outer end of the 
nail to a horizontal bar above the patient which ran the length 
of the bed (Fig. 7). 

November 3. 1 cm. shortening. 

November 12. Twenty-nine days after insertion, nail removed; 
no shortening; can raise knee slightly. 

November 14. Plaster spica applied. 

December 10. Cast removed (four weeks). Has good function. 
December 11. Z-rays show excellent position (Fig. 23). 



Fig. 23. Case V. Oblique fracture beginning just below lesser trochanter and going upward 
' through greater trochanter two months after fracture. 


December 29. Walks fairly well with one erutch. 

Epicrisis. Extension twenty-nine days; cast twenty-four days 
Uneventful course. Good result. 

Case VI. — ^Helen B., aged eleven years (Dr. A. G. Gerster’s 
service, Mt. Sinai Hospital). 

October 8, 1912. Was run over by an automobile. Sustained 
an oblique fracture of the left femur at its middle third. 

October 12. Vaginal smear contained gonococci. 

October 17. Ninth day after fracture, under gas and ether 
anesthesia; supracondylar insertion of a two-piece nail; 12 pounds; 
2| inches shortening (5| cm.). 




GERSTER; STEimiANN^S NAIL-EXTENSION METHOD 


October 20. 1| indies (3 cm.) shortening. 

October 24. Equal. 

October 27. 1 cm. overcorrection. Traction lessened to 9 

pounds. Slight adduction corrected by lateral pull 3 pounds. 



Fio. 24. — Case IT Oblique fracture of the shaft a few days after fracture. 


Fio. 25 Fto. 2(5 



Figs. 25 and 26. — Case VI. After one week of extension. 


October 31. Equal. 

November 8. Twenty-second day after insertion, nail removed. 
Good fibrous union. Slight false point of motion. 


gerster: steinjiann’s nail-extension method 179 

November 9. Pain in the right loin. Temperature, 100°. 

November 10. Vomited a number of times; pain in right loin 
increased; temperature, 104.2°; urine contained many red blood 
and pus cells. 

November 11 and 12. Temperature, 103° to 104°. Gradually 
subsided by lysis. Nail holes healed. 

November 14. Cast (spica) applied to hip and thigh only, 
allowing movement of knee. 

November 15. Temperature normal. 

November 21. Urine contains very little pus; no albumin. 

November 23. Cast removed; no shortening. Some bowing 
of the leg anteriorly. Has been walking on crutches for the past 
five days. 


Fig. 27 


Fig. 28 



r’lCTS. 27 and 28 . — Case VI. Pinal result eleven weeks after fracture. 


November 25. Discharged. 

December 23. Fell and bumped knee. 

December 27. Returned to the hospital for x-rays, which show 
good position (Figs. 27 and 28), Moderate effusion of the knee, 
which was treated with cold compresses. 

Epicrisis. Nail applied on the ninth day remained in place 
twenty-two days. Convalescence complictaed by a smart pyelitis, 
probably due to the vaginal infection. Slight anterior bowing, 
probably due to lack of support below knee while patient was 
wearing plaster cast. No infection of nail holes. This was the only 
case of the entire series in which it was possible to follow the effect 
of traction with the x-rays. 


gerster: steinmann’s nail-extension method 


Case VII. — ^Michael N., aged fifty-four years (Dr. S. M. Milli- 
ken"s service, Lincoln Hospital, New York). 

An extremely stout man who had varicosities of both legs for 
a number of years past. Non-alcoholic. He had been so asthmatic 
that he had been unable to work for the past six years. Five 
months before fracturing his thigh he contracted erysipelas of the 
right leg, and had stayed at home until the day of fracture, 
September 22, 1912, when he went out. He tripped stepping off 
a curb on his way to church and sustained a fracture of the upper 
third of the right thigh. Was taken to the Lincoln Hospital, 
where it was found, that besides the fracture, he had a mitral 
insufficiency and was extremely emphysematous. There was one 
inch shortening and marked eversion. A plaster spica was applied. 
The cast compelled him to lie flat; he nearly suffocated from his 
asthma that night, so that the cast had to be cut away from the 
abdomen in order to permit his sitting up. 

Fig. 29 Flo. 30 Fia. 31 



Figs. 29 and 30. — Case VII. Tracing of fracture of shaft in an obose man, 250 pounds, about 
5 feet 4 inches high, two days after fracture. 

Fig. 31. — ^Twenty-five days later; good callus. 


September 23, (Y-rays, Figs. 29 and 30). 

September 24. Cast removed. 

September 26. Fourth day after fracture, shortening approxi- 
mately 1| inches. Steinmann solid nail 21 cm. long; supra- 
condylar insertion. The thigh was so thick that the nail ends 
barely projected. No anesthesia; pain not extreme. 

September 27. Tongs applied; 15 pounds traction. 

October 2. Traction increased to 30 pounds; one inch shortening. 


gekstee: steinmann’s nail-extension method 181 

October 16. Nineteenth day, nail removed. _ Local decubitus 
from tongs where they grasped the end of the nail. Three-fourths 
inch shortening; no anterior motion; slight lateral motion. 

October 17. X-rays (Fig. 31) show slight overlapping and large 
callus. 

October 25. Dressing removed; wounds healed. 

November 1. Lifted entire leg from bed; active motion. 

November 12. Stood up for a moment (the first time) while 
being weighed; weight, 250 pounds. Out of bed in chair. 

December 1. Out on crutches; no limitation of motion. 

December 8. Discharged; on crutches. 

E'picrisis. An obese asthmatic individual, wholly unsuited for 
Lane plating or the usual Buck’s extension, in whom the nail- 
extension gave most satisfactory results. 



Fig. 32. — Case VIII. Taken shortly after fracture. 


Case VIIL— Arthur A., aged twenty-seven years (Dr. Ernest 
hahnestock’s service, J. Hood Wright Hospital, New York). 

November 8, 1912. A counter-weight of an elevator struck his 
eft thigh, causing a fracture at the middle third and rupture of 
the internal lateral ligament. (X-ray, Fig. 32.) 

November 22. Fourteenth day after fracture. Had been in 
a posterior splint for the past sixteen days. Slight fever ever 
pnce admission; 9 cm. shortening. Two-piece nail; supracondylar 
insertion; laughing-gas anesthesia; 16 pounds traction. 

ovember 23. Temperature, 102°. No local discomfort, 
'aeneral condition good. 



Ibi gerster; steinmann’s naii^extension method 

November 24. Temperature normal. .Traction, 21 pounds. 

November 25. 2 cm. shortening. Traction increased to 23 
pounds. 

December 1. 1 cm. shortening. 

December 4. No shortening. Edema of leg, which was present 
up to now, is nearly gone. 

December 24. Upon releasing weights there is 1 cm. shortening; 
plenty of callus; still some motion. ’ 

December 26. Nail removed (thirty-fourth day); 1 cm. shorten- 
ing afterward. 

December 29. 2| cm. shortening; nail holes clean; union im- 
proving; 30 degrees motion in flexion of knee (T’-ray, Fig. 33). 



Fig. 33. — Case VIII. Two months later. The nail extension was applied fourteen days 
after fracture (9 cm. sliortening). At present 1 cm. short — front and side view. 


January 3, 1913. Firm union. Function of knee much better. 

Epicrisis. Nail-extension was applied fourteen days after frac- 
ture and was maintained thirty-four days. The 9 cm. shortening on 
the sixteenth day was reduced to nil. There was delayed union. 
This accounted for the shortening which came after discontinuance 
of traction. A two-piece nail was used, and it was deemed unwise 
to use more than 23 pounds traetion for fear of breakage. 

Case IX. — Charles H., aged fifty years (Dr. John A. Wyeth's 
service. Polyclinic Hospital). 

November 22, 1912. Patient was standing on the end of a 
freight train, which was backing down. The train suddenly 
stopped, threw him off, and he became unconscious. He sustained 
a traumatic amputation of the big and second toes of his right foot, 
a fracture of the upper third of his right femur, and a concussion 
of the brain. 


WIM 



GERST^iRt STEINiMANN^S NAIL-EXTENSION METHOE loo 

November 25. Third day after fracture, solid nail inserted 
under laughing-gas anesthesia; 12 pounds traction; one inch 

shortening. . 

November 28. No shortening. Traction wire brolce. 

December 1. 1 cm. shortening. 

December 16. Twentj^-first day, no shortening; apparent union; 
nail removed; removal required considerable force. 

December 21. Wounds healed promptlj^ 

December 30. A^-ray (Fig. 34). Revealed a badly comminuted 
fracture of the neck and trochanter. The fragment indicated by 
the arrow was palpable and led to the diagnosis made above. 
Today there is three-fourths of an inch shortening. Abduction 
will be maintained by a cast. 



Fig. 34. — Case IX. Comminuted frac- Fig. 35. — Case X. End-result six weeks after 
ture of greater troehanter and shaft comminuted fracture of shaft. No shortening, 
(thirty-eighth day). 


Epicrisis. The crushed condition of this man’s foot would 
have made proper attention to it difficult had a Buck’s extension 
been applied. As it was, dressings were not hindered by the nail- 
extension apparatus. This case emphasizes the value of con- 
trolling clinical observations by the .r-rays. 

Case X. Charles C., aged nine years (Dr. Ernest Fahnestock’s 
service, J. Hood Wright Hospital, New York.) 

November 23, 1912. Patient was hit by an automobile and 
sustained a fracture at the middle third of his left thigh. 

December 2. Eight days after fracture there is a large effusion 
of the knee-joint. 2 cm. shortening. Under laughing-gas anes- 
thesia; a solid nail inserted through the head of the tibia; 10 
pounds traction, which was increased later to 15 pounds. 

December 4. 1 cm. over correction; effusion less. 

December 13. Effusion of the knee-joint gone. 


184 GERSTER: STEINMANN’s NAIL-EXLENSION METHOD 

December 24. Twenty-one days after insertion, nail removed 
easily; good union; large callus. 

December 29. Nail holes clean. Can raise knee twelve inches 
from bed; active or passive flexion beyond this is painful. 
December 30. Out of bed on crutches. (X-ray, Fig. 35.) 


CASES IN WHICH NAIL-EXTENSION WAS APPLIED AND WHICH-. 
DIED FROiM CAUSES HAVING NO RELATION TO THE 
METHOD EMPLOYED. 

Case XI. — ^Alice K., aged fifty-two years (Dr. Collins’ service. 
City Hospital). 

September 13, 1912. Patient broke her right hip. 

September 20. Supracond 3 dar insertion of Steinnaann’s two- 
piece nail by Dr. H. H. JanewajL 



Fio. 30.— Case XI. Total absorption of femoral neck three days after fracture in a sjTjhilitic 
subject. The head lies against the shaft. 


September 21. Wassermann reaction was reported strongly 
positive. On account of her debilitated condition, she bore 
antispecific treatment poorly. 

October 7. Seventeenth day after insertion, local pain around 
the nail; temperature, 102°. 

October 10. Twentieth day, fever having continued, nail 
removed; 2 drams of pus escaped; nail was found broken at the 
screw-joint; but the ends of the tongs had kept the pieces of nail 
in position at approximately right angles to the bone. 

October 11. Temperature normal; discharge less. 



gekstek: steinmann’s nail-extension method 185 

October 15. No union. Z-rays show total absorption of the 
femoral neck, so that head rests against shaft (Fig. 36). 

October 18. The patient has been gradually declining for the 
past two weeks. During the past week there has been no fever; 
she became much weaker this day; went into coma and died. 
Diagnosis: Death from sj^Dliilitic myocarditis. No autopsy, 

Epicrisis. This was a fracture of the neck of the femur in a 
markedly syphilitic subject. Total absorption of the neck in 
thirty-two days. It is possible there was a previously existing 
gumma of the neck of the femur, predisposing to fracture at that 
point. The patient was intractably filthy in her habits. Inflam- 
mation of the nail hole, which occurred on the seventeenth day 
after insertion, promptly subsided after removal of nail and appli- 
cation of wet dressing. Patient died of her myocarditis a week 
after her temperature had reached normal. The nail broke at its 
joint under no undue strain. (Traction between 10 and 15 pounds.) 



Pia. 37.— Case XII. A two-piece nail which broke at the joint. The pieces were held at 
approximately right angles by the tongs and continued to exert traction. 

Case XII.— Fritz D., aged forty-eight years (Dr. Collins’ 
service. City Hospital). 

October 27, 1912. A confirmed drunkard, fractured his thigh 
while intoxicated. Had delirium tremens four days after admission. 
iViouerate icterus. Condition gradually improved. 

tatTor^^^^ no anesthesia; 19 pounds 

November 2. Comfortable. 

November 3. Apin developed delirium; irrational. Developed 
a pneumonia, to which he promptly succumbed. 

delirium, show broken 

nail held m place by tongs (Fig. 37). No autopsy. 

TOP. 146. NO. 2.— AtJQTJST, 1913 7 



186 


hochwart; the internal secretions 


THE RELATIONS OF INTERNAL SECRETION TO 
MENTAL CONDITIONS.! 

By Professor Doctor L. V. Frankl Hocbtolvrt. 

pnoFESson op nbbvotjb diseases in the tinivehsitt of Vienna, Vienna, adstbia. 

The subject of internal secretion has aroused much interest 
among physicians during the last decade, and detailed investi- 
gation has furthered the work. As a matter of fact the relations 
of glandular secretions to the nervous system have been note- 
worthy. We find observations on the influence of the secretions 
on psychic conditions, to which may be added attempts to influence 
certain ps^'^chic conditions curatively by organic extracts (opo- 
therapy), also the scientific movement which defines changes in 
the glands as phenomena resulting from psj’^chie anomalies. 

Nor have attempts been lacking to present clearly the matters 
in question, particularly the report of Laignel Lavastine at the 
Congress of Dijon and the reviews of Bauer, Marburg, Muenzer, 
and others. 

Observations on operated animals are of particular importance, 
the investigations on the hypophysis by Cushing, Aschner, and 
others being interesting examples. 

In the effort to give an outline of our present knowledge, based 
on the work done by myself and other investigators, I feel that 
the facts are incomplete, that hypotheses must play too great a 
part therein. Still, the investigations have accomplished sufficient 
to present a review which is not uninteresting, and it is neces- 
sary to compile such a review, premature though it may seem, if 
only to point out the way which furture studies must follow. 

The oldest problem of internal secretion is the action of the 
genital glands. The peculiar effect of the testicle extracts observed 
by Brown-Sequard was the first evidence of an internal secretion. 

In older literature it was affirmed that not only the entire nature 
of woman, but her character as well depended on the reproductive 
organs. Heimont said, “Propter solum uterum mulier est quod 
est;” Chereau said, “Propter ovarium solum mulier est, quod 
est;” and Virchow’s statment that a woman is a woman simply 
because of her generative gland is familiar. The peculiarities of 
her body and mind — ^in short, all the femininity which we admire 
in the true woman — are dependent on the ovary. This inter- 
pretation is not unimportant if we reflect that modern study of 
the brain, otherwise so rich in results, has not succeeded in 
discovering differences between the male and female individual 

I Lecture delivered at theMedical Department of University of California, September 3, 1912. 



187 


hochwaet: the internal secretions 

which would be able to explain the psycHc differences between 
botll S6XGS. 

So long as the genital glands do not enter into energetic func- 
tion— in childhood— the secondary sexual characters are scarcely 
indicated. The psychic differences are often recognizable as early 
as the second and third year, become more marked in later years^ 
and the differentiation becomes pronounced only after puberty. 
The study of this period of development becomes the more inter- 
esting when we compare the powerful ascendenie with the later 
decrescente of the climacterium in man and woman. 

Let us begin with man. Puberty is preceded by a certain unrest, 
a noticeable vacillation, sometimes a sort of fear; only then the 
erections and pollutions begin. The voice changes — ;it becomes 
rougher and deeper. The thyroid gland becomes larger; the genital 
and axillary hair appears, and the body grows more hairy in gen- 
eral; the beard becomes apparent; the epiphyseal cartilages begin 
to ossify. The psychic changes come into the foreground; childish 
plays are dropped; reading takes a higher course. New energy 
takes possession of the young man — ^the ambition to perform great 
deeds, to act for great ideas, and frequently the inclination to 
solve the world’s problems. Anxious doubts as to the doctrines 
of religion, hitherto believed in with childish simplicity, vary with 
emanations of an unhealthy and exaggerated religious faith. Diffi- 
dence alternates with self-confidence and self-consciousness. Plans 
of reforming the world are formed. Conduct toward the female 
sex is strained. Games with girls are regarded with scorn, and 
the opinions of women in general are held in contempt. In odd 
contradiction to this, bombastic declarations often come freely 
from their lips; they are bashful in their association with women; 
and they adore some particular female, whom they would never 
venture to address, with the romance of a troubadour. Here we 
see strongly indicated what every man retains in some measure, 
and what every woman possesses — a certain unconscious antipathy, 
in some respects, to the other sex. There is here something mys- 
terious — something that cannot be bridged over. In these young 
men there is also often a tendency to mysticism. Eroticism and 
mysticism are matters wMch often go hand in hand. It is the age 
of sentimentality/ in which the German youth tries with more or 
less success to sing in the rhythm of Heine. 

However,^ especially in those with a neuropathic tendency, this 
sentimentality becomes too deep. This is the times of the steadily 
increasing number of youthful suicides; also the appearance of 
youthful psychoses, which in their incipiency so often present a 
caricature of awakening sexual life. 

The period of sexual tempest in adolescence is succeeded by 
the period of young manhood, also dominated by strong sexual 
emotions, which now follow quieter paths. But the tempestuous 



188 


hochwart: the internal secretions 


still has the upper hand. The age of genuine love begins, which 
cannot be explained scientifically. The cortical excitability in- 
creases; often, also, the _ intellectual capacity. Birds sing at the 
time of mating. Man’s imagination broadens; the poets sing their 
best songs; the musicians compose their most beautiful music; 
discoverers and inventors often do their best work when in love 
(Ostwald). 

In observing the processes before and after coitus the influence 
of the secretion of the sexual gland is much in evidence. The 
strong, stormy, psychic excitement, at times combined with a 
certain mental incapacity, which precedes coitus is often followed 
by a sort of transitory antipathy to the same woman so passion- 
ately longed for a short time before. Coitus at normal intervals acts 
favorably on the mental condition, and excesses are injurious. 

Observation of onanists gives further proof of the influence of 
genital secretion. It is generally believed by physicians that 
isolated onanic acts do not materially injure the individual, but 
when the secretion is excited too often those who are addicted 
to this habit become weak, abulic, averse to society, and show 
decrease of intelligence and memory. 

The much-discussed question of sexual abstinence in vigorous 
men must be here touched upon. Some men seem to tolerate 
easily this abstinence, but in others psychic symptoms may be 
observed in the stage of abstinence, unrest, melancholy, general 
discontent, symptoms which sometimes decrease after sexual sat- 
isfaction. This symptom-complex seems to occur more often in 
persons with a neuropathic tendency. 

Men also present a peculiar picture at the time of cessation of 
the internal secretion of the genital glands, although not in the 
same degree as woman at the critical age. The picture has been 
described in detail by Mendel. We have to deal mostly with men 
of forty-seven and fifty-seven years of age, who show reduced or 
absent sexual desire and potency, but who were often previously 
healthy and strong. Now they are nervous, emotional, often 
break into tears, have attacks of perspiration, palpitation of the 
heart, show lassitude, and are sleepless. At times they ■ have 
attacks of giddiness and headache; often there are diffuse bodily 
pains and paresthesias. The memory grows dull, mental interests 
decrease, and the patients manifest hypochondriac ideas. 

But other psychic changes in aging men, changes that are 
beneficial to humanity, must not be forgotten. At the decline 
of sexuality psychic rest often develops— peaceful calm, a clear 
view and review of life, and a tendency to mildness. These- are 
the men who no longer produce new and enthusiastic ideas, but 
who as teachers and guides fully grace their position. As judges 
they are in their fittest place. The men with strongly secreting 
genital glands have too much temperament for such office, and 



i-iochwart: the internal secretions 


189 


too much. pRssiou. A German sta-tcsiURii is alleged, to have said 
that only two things grow better with age, wine and judges. 

Experiences in regard to castration are particularly instructive. 
In the animal Idngdom this operation is often practised on domestic 
animals — stallions, bulls, rams, cocks, and birds. We know that 
if these animals are castrated early they not only develop differ- 
ently in body, but change their psycliic conduct and lose their 
liveliness and aggressiveness. Not only is the outward appearance 
of the early castrated known, but the peculiarities of their char- 
acter have been often discussed; they are thought to be cunning, 
secretive, avaricious; they often love dress and jewelry to excess, 
and they have no great executive ability. Moebius states that in 
Italy eunuchs have frequently had great success as music virtuosi, 
especially as singers; but that in productive art, that is, composi- 
tion, they are not successful. The influence of late castration, 
mostly for surgical reasons or because of injuries, has been frequently 
discussed in literature. In these persons bodily changes are little 
noticeable; on the other hand, conditions of depression and 
psychoses are found relatively often. 

In certain conditions associated with inferior or undeveloped 
genitals, in infantilism and eunuchoids (Tandler and Gross), lighter 
or more severe degrees of imbecility are not infrequently found. 
Men with even slight genital affections often suffer from severe 
depression. 

From what has been said, we see what a great influence the 
genital organs, with their secretion, have upon men. 

In regard to women, we find that the time of puberty is char- 
acterized not only by the somatic signs of the appearance of men- 
struation and the secondary sexual attributes, but also by psychic 
changes. Young girls become restless, nervous, apprehensive, 
dreamy. Months often pass before the proper equilibrium is 
reestablished. The psychoses present at this time differ from those 
in boys. The progress of intelligence becomes marked in boys 
during the puberty. Girls between the ages of eighteen and 
twenty-two, that is, when sexual conditions have calmed down, 
often attain a remarkable mental elevation (Moebius). The 
strong imagination, quick conception and comprehension are 
often remarkable at this age. 

In the further progress of her life the periodical menstruation 
shows not only somatically as bleeding, but also in the entire 
make-up of the woman and here, again, psychic factors are evident. 
Menstruation is preceded by a certain irritability and a slight 
psychic stagnation. When the hemorrhage appears women have 
a feeling of lassitude, become abulic, and less active intellectually. 
Icard (in Havelock Ellis, from whose studies we quote liberally) 
observes that in perusing the diary of a young girl it does not 
require much perspicacity to discover the pages which wmre wuitten 



190 


IIOCHWART: THE INTERNAL SECRETIONS 


during menstruation. Among 80 'women wlio. were arrested for 
resisting the police, Lombroso found only 9 who were not men- 
struating. Among 56 female shoplifters, Legrand du Saulle found 
35 who were unwell at the time of the crime. Suicides are known 
to be frequent at the time of menstruation. A. Pilcz found intra- 
menstrual changes of the sexual organs in more than one-third 
of female suicides. The question of the not infrequent insanity 
during menstruation has likewise been discussed. Recent inves- 
tigations have shown that menstruation in women is not a suddenly 
appearing and disappearing event. On the contrary the organism 
seems to be in a continuous wave-like movement which is not found 
before the beginning or after the close of menstruation in childhood 
or old age. Perhaps the much-discussed variability of mood may 
be explained thereby, the often inexplicable vacillation of mood 
in the sexually mature woman. 

_ Pregnancy and the puerperium play a peculiar part in a woman’s 
life. As regards the puerperium, we have to deal only with that 
which takes its course without fever. Even women otherwise 
not psychopathically inclined usually become nervous and easily 
depressed during the time of pregnancy. Neuropathic natures 
at such times often have a tendency to severe depressions, with a 
tendency to suicide. The frequency of psychoses in this condition 
is well known. In exceptional cases, remarkable contrasts to this 
picture are observed. Some women almost habitually suffer from 
severe depression, being mentally most calm, even during pregnancy. 

The psychic disturbances of the climacterium, the most danger- 
ous and critical age of woman, have also been much discussed. At 
the time when menstruation begins to be irregular — sometimes 
even months or a jmar before — women fall into a strange state 
of unrest, sometimes accompanied by sexual overexcitability. 
Deep depressions, a tendency to outbreaks of weeping, periods of 
irritability, psychic vacillation, and a decrease of intelligence are 
well-known conditions in most women at this time. But in some 
cases it reaches a high degree: psychoses of depressive character 
are often established. The gossipy character of the old hag has 
also been mucli discussed. The messenger of misfortune in fairy 
tales is almost always an old witch. If for reasons of local diseases 
castration is performed in women, phenomena appear, similar to 
those above described, only less pronounced and the effect of 
late castraction on the mental condition is not nearly so great as 
on men; but literature has many examples of psychoses after the 
operation mentioned. Nothing accurate is Icnow'n about the psychic 
condition of women after early castration. The undoubted influence 
of genital affections of the most varied kinds on the mental con- 
dition of women has been much discussed. How deeply rooted 
the conviction ©f this influence has been is shown by the opinion 
of the connection between hysteria and the genital organs and by 



191 


HOCmVAHT; tHE internal SECeETIONS 

the repeated attempts of gynecologists to cure serious hysterias 
by castration. 

The thyroid gland is the most interesting organ for the study 
of internal secretion. It is indeed the only organ in which we can 
differentiate hyperfunction and hypofunction clinically^ and experi- 
mentally. The hyperfunction appears most distinctly in Basedow's 
disease. In 1909 R. Stern in Noorden's dispensary, reviewed my 
Basedow material, covering a period of twenty-five years, and 
found that we must distinguish certain definite groups. Basedow's 
disease is marked by rapid beginning and rapid growth of the 
struma, by pronounced trembling, extraordinary tachycardia, and 
increasing exophthalmos. These typical affections mostly befall 
individuals without hereditary tendency. In a number of cases, 
however, we have to deal with hereditary affected individuals, 
mostly persons who have for years been suffering from nervous 
symptoms (degenerative Basedow). 

But the recognition resulting from investigation, that the so- 
called “formes frustes" differ greatly from the principal ones and 
have the tendency to change into the genuine, is important. They 
must be considered as a separate group of diseases. There are 
individuals who even in youth have a struma, though only a mod- 
erate one, which usually does not grow, or very little, afterward. 
The other symptom-complex develops sporadically only, and not 
to an unusual degree; the exophthalmos is often altogether absent 
or only indicated. In this group the mental condition is also 
changed. They are often grumbling, hypochondriac, melancholic, 
and egotistic persons. 

The study of the cases is more important in which psychic anom- 
alies may appear in various forms. But one tendency is often 
pronounced — ^namely, the predominance of manic features. The 
individuals are often excited, though we cannot exactly speak of 
a psychosis. They are talkative, spasmodic in their thoughts and 
actions, and sometimes incline to witticisms. In conversation they 
often prefer erotic subjects, and are given to sexual excesses. In 
the acute psychoses of these patients there may be a predominance 
of manic features. 

I remember the first case in my practice. It was that of a woman, 
aged twenty-one years, who grew rapidly nervous, and in whom 
there developed simultaneously the various components of the 
typical Basedow, noth an unusually excessive exophthalmos. 
Except for a certain excitability the patient seemed normal, and 
she was sent to the seashore. But her mental condition changed 
for the worse. I hastened to see her, and when I entered the gate 
she came to meet me, singing gaily, her hair loose and wreathed 
with flowers. The physical disease lasted for several weeks. The 
excitement, which had abundant erotic features, grew considerably. 
There was no defect of intelligence, no pronounced confusion of 



192 


IIOCIIWART; THE INTERNAL SECRETIONS 


ideas, no hallucinations. After a few months the condition im- 
proved. Gradually the permanent cure of the psychosis resulted 
and at the same time the Basedow symptoms disappeared. 

Opposed to the picture of Basedow disease, of hypertrophy of 
the thyroid gland tissue, we have the picture of atrophy and degen- 
eration. The somatic and psjmhic pictures bear the relation, says 
Weigandt, of the photographic positive to the negative. Most 
striking is the condition of the adult myxedematous patients, 
with the typical absence of the thyroid gland. The principal 
factor is the complete lack of emotion. A considerable role is 
ascribed to the thyroid gland in emotional life. According to 
Levi and Rothschild it is the “glande de Temotion.” The simi- 
larity of the picture of fear emotion and that of- Basedow’s disease 
should be remembered, also the lid fissures, the protuberance of 
the bulbi, the trembling, the tachycardia, the congestions which 
alternate with pallor, the outbreaks of perspiration, the diarrheas, 
the trembling of the legs. 

As emotional as are those afflicted with Basedow’s disease, so 
lacking in emotion are the myxedematous. According to Charcot 
they may be compared to hibernating animals: dull-witted, indiff- 
erent, unable to work, disinclined to sexual activity, the memory 
gradually decreases, the power of judgment becomes minimal, 
and the patients often lie in bed apathetically for days, almost 
Avithout desire for food or drink. Severe psychoses are by no means 
rare in these patients. The connection between the mental con- 
dition and lack of the thyroid gland may best be studied if thyroidin. 
be administered for therapeutic purposes. It is then often sur- 
prising to see the apathetic and indifferent become Ihmly and 
communicative and evince signs of intelligence which would not 
have been considered possible a short time before. 

The significance of the thjToid gland also becomes clear on 
examination of children Avith congenital or acquired myxedema. 
The mental inferiority of cretins, Avith defective or degenerative 
thyroid glands is well-known. The psychic picture may be improved 
by administering thyroidin ( Wagner- Jauregg). 

Muenzer refers to the well-known swelling of the thyroid gland, 
with processes in the genitals, in puberty and in pregnancy.^ In 
gravidity the hjqiophysis shows marked changes. There is a 
mutual action betAveen the glands — every affection may be poly- 
glandular — and some attribute the affection to a single gland. 

We cannot leave this phase of the subject Avithout a word on the 
parathyroid glands, the four accessory glands of the thjToid, which 
differ from the genuine not only in liistological structure, but also 
in function. Clinical investigations (Jaendelize, Pineles, Vassale, 
Jenerali, Erdheim, and Riedl) have shown the probability of tetany 
being a consequence of the affection of these organs. In 1889 i 
described psychoses in indiAudualswho had fallen ill of typical tetany. 



hociiwart: the internal secretions 


193 


At the culmination of the affection, which in Vienna^ appears in 
March and April, typical tetanic attacks appeared which subsided 
with the symptoms of somatic affection. Similar cases were also 
described by other authors, especially cases of a strumipriye or 
parathyreoprive form. The mood of those afflicted by tetany is not 
to be designated as normal, even if we do not consider the actual 
psychoses. These individuals are exeitable, timid, uneasy, quarrel- 
some, and inclined to outbreaks of temper. Depression is occa- 
sionally present, but is not one of the dominant symptoms. In 
the psychoses the conditions of temper and excitement predominate. 
I found among my old patients vdth tetany several who had grown 
excitable and irritable. In those who had myxedematous phe- 
nomena the symptoms of mental lassitude appeared which were 
not recognizable in the other forms. 

In strumectomized animals peculiar psychic changes have been 
described. Blum mentions hallucinations in strumectomized dogs, 
as well as changes of characteristics, idiocy, and pathologic motion 
phenomena. Horsley and Pineles saw similar phenomena in 
monkeys. Erdheim observed conditions of excitement in rats, 
and stated that these are connected in some way with tetany, as 
on the days when the animals are excited tetany often reappears. 

Our loiowledge of the thymus gland is still small, though Basch 
and Klosevoigt refering to the feeble intelligence of animals whose 
thymus had been extirpated, speak of an “idiotic thymopriva.^’ 

We know more about the so-called brain glands, the hypophj^sis 
(pituitary body) and the epiphysis (pineal gland — glandula pin- 
ealis), and during the last decade many important side-lights 
have been thrown on the question of their influence on mental 
condition. 

Engel of Vienna, in his dissertation on the pituitary body in 
1839, gave expression to his ideas on this subject. 

The hypophyseal affections have to be divided into two large 
groups, the acromegalia and the dystrophia adiposogenitalis 
(Frohlich’s type). Psychoses of various Idnds in these conditions 
have been described. Schuster has treated this subject in detail. 
He found that tumors of the corpus callosum probably cause 
psychic disturbances; frontal lobe tumors, 80 per cent., temporal 
lobe tumors, 66.6 per cent., the hjTiophyseal tumors, 65.3 per cent. 

Boyle and Beadles among 3000 necropsies at the lunatic asylum 
found tumors in 20, 6 of them hypophyseal. The number of actual 
hjqiophyseal psychoses is somewhat overestimated. Large brain 
tumors which because of increase of brain pressure and destruction 
of brain parts may eo ipso call forth psychoses are encountered. 
But the fact that psj^choses are so frequent in affections of the 
pituitary body gives food for thought, in spite of their association 
at times with destruction of tissue in other parts of the brain. 
I have seen many pituitary'' body tumors, and have noticed a 



194 


hochwart: the internal secretions 


psychic change, a peculiar indifference, a certain contentment, 
a euphoria which is not in harmony with the symptoms, such as 
headache and blindness. The patients are calm, and have a childish 
confidence in the doctor. The sleepiness of the patients is pro- 
nounced, but if they are forced to arouse themselves, their intelli- 
gence has not suffered nearly so much as we would be led to believe 
by the outward impression they make. 

The psychic factor may best be studied by observing operated 
cases. I have seen cases operated on either by the Schlolfer (cases 
of y. Eiselsberg and Hochenegg) or the nasal method of Hirscli. 
It is remarkable how livelj^ agile, and communicative the patients 
become. The entire psychic condition of the corpulent partakes 
of the condition of individuals with constitutional obesity. The 
peculiar mental slowness, indecision, good nature, and sleepiness 
of these people is proverbial. Loss of hair is not uncommon. 

It is not uninteresting to compare the acromegalic with the 
physiologic giants. They often have a peculiar heavy manner 
and lack of initiative. The psychic peculiarity of hypophysis 
patients, which we described in our report at the International 
Congress at Budapest in 1909, is of interest from the fact that the 
animal experiments of Cushing in Baltimore and Aschner in 
Vienna showed that in hypophysectomized dogs the psyehic changes 
corresponded with those of human beings. According to Cushing, 
animals with hypopituitarism become psychically abnormal: at 
times they are lazy and sleepy, then playful and excited. 

If in early childhood tumors (teratoma) develop on the glandu- 
lar pinealis a picture is presented which is more intelligible since 
the obserAmtions of Gutzeit, Ogle, Oesterreich, Slavik, Neumann, 
h'larburg, Baileys and Jelliffe. The features of premature sexual 
development are combined with an unusual development of fat. 
In a boy, aged four and a half years, who had always been very 
large and somewhat fat, the genitals developed remarkably. In , 
liis fifth year erections appeared, the voice became deep and hoarse, 
.and the body showed a hirsute appearance which corresponded to 
the age of eighteen or twenty'^ years. He had the symptoms of a 
cerebral tumor (headache, vomiting, epileptic attacks, paralysis 
of the eye muscles, and choked disk). He died of scarlatina. The 
necropsy’^ findings showed a teratoma of the pineal gland. One 
point in this observation is of importance, the early development 
of the mental condition. The boy was overintelligent, and had an 
inclination to discuss ethical philosophic questions. In his fifth 
year he showed the same psychic peculiarities that are display^ed 
by y'^ouths during the development of puberty''. 

There Avere also signs of early'^ psychic development in the cases oi 
Oesterreich and Slawyk and Raymone and Claude. The hypothesis 
therefore was that the pineal gland was to be considered among 
the blood glands, and that it influenced genital development. Its 



SEELIG, TIERNEY, RODENBAUGH: SODIUM BICARBONATE 195 

absence causes premature genital development and psychic develop- 
ment corresponding to the age of puberty. Descartes placed the 
seat of the soul in the pineal gland, and although in this form his 
belief cannot be upheld, still when a genius has once made an 
assertion, something of it will always remain. 

Of the abdominal glands the pancreas and its internal secretion 
play a large part in relation to diabetes. Diabetics often show 
mood anomalies, and we speak of actual diabetic psychoses. We 
have no test for determining how far the psychic peculiarities 
depend on the secretory disturbances of the pancreas. 

The study of suprarenal capsule affections gives us more positive 
points of knowledge. The secretion of these organs and their 
effect on the nervous system are generally known. The connection 
between disturbances of brain development and hypoplasias of 
the suprarenal capsules, is of importance in the subject under 
discussion. Leri in 3 cases of melancholia found destruction of 
the suprarenal capsules. At the clinic there are occasional cases 
of Addison’s disease with a tuberculous destruction of the organs 
mentioned. These individuals are weak, exlaausted, and hopleess, 
in contrast to the euphoric patients with tuberculosis of the lungs. 
Irritability and depression are almost always present. 

Psychoses of various kinds have also been observed in which de- 
pression seems to predominate. In addition to the observations of 
Leri, we refer to the histories of Bonhoeffer, Vollerecht, Rodionow, 
Boinet, and Klippel. 

From this review it will be seen that we know of a number of 
the effects of internal secretions on mental conditions, and how 
the development of the mind depends on these secretions. Brain 
anatomy helps but slightly in showing how higher mental develop- 
ment is to be explained. Perhaps the time will come when we shall 
learn to perceive how much depends on the individual structure 
of certain glands and on their individual internal secretion. 


AN EXPERIMENTAL STUDY OP SODIUM BICARBONATE AND 
OTHER ALLIED SALTS IN SHOCK. 

By M. G. Seelig, M.D., 

PROFESSOR OF SORGEBT, ST. LOUIS UNIVERSITY, 

AND 

J. Tierney and F. Rodenbaugh, 

ST. LOUIS UNITERSITT. 

(From the Physiological Laboratory of St. Louis University.) 

In recent literature there is a vast preponderance of work on 
the various possible causative agencies of shock and practically a 



196 SEELIG, TIERNEY, RODENBAEGH; SODimi BICARBONATE 

dearth of investigations directed toward the therapeutic relief of 
this serious symptom-complex. Howelh in 1903, was led by a labor- 
atory accident to investigate the physiologic action of sodium 
carbonate and found this salt to be an excellent cardiac stimulant 
in shock. Henderson, 2 in 1910, as a result of his extensive investi- 
gation of acapnia, suggested as a rational therapy for shock the 
prevention of loss of carbon dioxide (the carbon dioxide being lost 
chiefly as a result of hyperpnea and by exhalation from exposed 
viscera) and the replacement of such loss, as had previously 
occurred, by increasing the dead space of the respiratory tract. 
These two investigators furnish about the only new lines of thera- 
peutic thought developed during the past decade on the subject 
of shock. 

Howell’s work is important in that it demonstrated both the 
pronounced action of sodium carbonate on the force of the heart 
beat and also the duration of this effect over a comparatively 
long period of time. According to Howell, the rate of beat was 
unaffected, and vascular tone, likewise, in all probability was not 
influenced. In severe degrees of shock, sodium carbonate did 
not yield the brilliant results secured bj'- the use of this same drug 
in the more moderate cases (where the blood pressure registered 
60 to 70 mm. of mercury) ; but even so, to quote Howell, the results 
were more hopeful “than those obtained by the use of other sub- 
stances suggested as having value. Adrenalin, hypophysis extract, 
alcohol, and strychnine gave negative results or, at best, temporary 
and unimportant rises.” The nucleus of Howell’s work, though 
not expressly so stated by the author, lies in the thought that the 
pressor effect of sodium carbonate is due to its alkalinity. Dawson® 
extended Howell’s work by using sodium bicarbonate, but in his 
experiments he induced shock by bleeding his animals, thus com- 
plicating an already complex set of phenomena by the added ele- 
ment of hemorrhage. Henderson’s work, in its turn, is important 
in that it reviews and reemphasizes the importance of carbon 
dioxide as a body hormone, and particularly in that it points out 
the absolutely fundamental fact that in all probability the low 
blood pressure which results from venopressor disequilibrium is 
not the principal causative factor of shock, as it is so generally 
assumed, but is rather the direct result of .shock. Henderson’s 
main line of thought may be sketched as follows; As a result of 
various factors— pain, excessive flow of afferent impulses, or expo- 
sure of viscera — there is a loss of carbon dioxide either by excessive 
lung ventilation or by direct exhalation from the viscera. Carbon 

1 Observations upon the Cause of Shock and the Effect upon it of Injections of Sodium Carbo- 
nate, Contributions to Aledical Research, dedicated to V. Vaughan, 1903. 

I A series of Papers on Acapnia and Shock, Amer. Jour. Fhys„ xxi, 126; xxiii, 345; xxiv, 60; 
XXV, 310; xxvi, 200; xrvii, 152; Johns Hopkina Bulletin, August, 1910. 

» Changes in Heart Rate and Blood Pressures Resulting from Severe Hemorrhage and Subse- 
quent Infusion of Sodium Bicarbonate, Jour. Exper. Med., 1905/ vii, 1, 



SEELIG, TIERNEY, RODENBAUGHt SODIUM BICARBONATE 197 

dioxide is an important though poorly understood regulator (hor- 
mone) of many of the vital functions (cardiac, peristaltic, respna- 
tory, venopressor), consequently when the loss of carbon dioxide 
becomes quantitively sufficient these vital functions are thrown 
out of gear up to the point of compromise or further, even to cessa- 
tion of activity. Contrariwise, balance may be restored by methods 
adapted to increasing the deficient carbon dioxide content of the 
blood. Henderson’s^ views have been vigorously attacked by 
physiologists, and his own data has been used to disprove his main 
thesis. But leaving aside all polemic discussion it m.ay be stated 
fairly that if in accordance with Henderson shock is caused by 
acapnia or a lessened carbon dioxide content in the blood, then 
the direct introduction of carbon dioxide into the blood ought to 
be a powerful and fairly certain remedial agent.^ 

On the above assumption we based the following series of experi- 
ments. Before describing our experiments, however, it must be 
stated that two essential facts were kept constantly in mind, 
namely; (1) Blood-pressure readings in shocked animals must 
be interpreted merely as expressing phenomena, coincidental 
with and not necessarily causative of shock. Attention is centred 
largely on blood pressure because it is conveniently measurable 
accurately and graphically, and because, in a sense, it furnishes 
an index of the degree of shock. (2) In the anesthetized dog there 
are remarkable spontaneous variations of pressure which, as far 
as can be determined, have nothing except a coincidental relation- 
ship with procedures aimed at either producing or relieving shock. 
These variations in pressure will necessarily be falsely interpreted 
unless a large number of control experiments are performed as 
routine work.® 

Assuming the correctness of Henderson’s assumption that shock 
is due to a deficiency of carbon dioxide in the circulatory blood, 
we attempted to check up his theory by supplying the blood stream 
directly with an increased quantity of this gas. For obvious reasons 
the demands of accurate experimentation would not be satisfied 
by iffiusing a solution of carbon dioxide in water or in an isotonic 
medium. In our earlier experiments we were deterred from intro- 
ducing pure carbon dioxide gas into the circulation by the fear of 
gas emboli, therefore it was determined to use a molecular solution 


• Henderson himself attempted to increase the carbon dioxide content of the blood by two 
methods, both of which are open to criticism. His method of infusing physiologic salt solution 
saturated with carbon dioxide is open to question on account of the bulk of fluid necessarily 
injected (Henderson does not furnish figures or details of these infusions) and his method 'of 
increasing the dead .space of the re^iratogy tract is open to criticism because it is not accom- 
panied by analysis of the lung and blood gases before and after. 

‘ The conclusions on which this paper is based rest upon a hundred odd experiments performed 
on forty-six dogs. AU the experiments were perfomjed with the animal under profound morphine 
^rehant (chloroform) or morphine ether anbsthesia. We are deeply indebted to Dr. B. F. 
May for yaluable assistance rendered during the summer of 1911 in a large series of experiments. 



198 SEELIG, TIERNEY, RODENBATJGH: SODIUM BICARBONATE 

of sodium bicarbonate. There are three elements in the blood which 
split up the sodium bicarbonate molecule and set free carbon dioxide; 
(1) The hemoglobin; (2) the serum albumin; (3) the primary (acid) 
sodium phosphate. It will be seen therefore that the introduction 
of a solution of bicarbonate into the blood stream furnishes a direct 
and immediate increase of the carbon-dioxide content. 

We may say at the outset that, without exception, every infusion 
of sodium bicarbonate caused a pronounced rise of blood pressure. 
In our first experiment, in which we introduced intravenously 
200 c.c. of an 8.4 per cent, solution, the rise w^as so remarkably high, 
so long continued, and so notably in contrast with the efficiency of 
all the other antishock drugs and procedures that we had tried dur- 
ing the past five years that the practical therapeutical phase of the 
problem almost overshadowed the purely scientific inquiry regard- 
ing the influence of the carbon-dioxide content of the blood. A 
molecular solution of sodium bicarbonate was injected fifty times 
under varying conditions of blood pressure. An analysis of the 
results obtained from this set of experiments furnishes the follow- 
ing facts: (1) When 25 c.c. of the solution is injected into a normal 
(anesthetized) dog, with normal blood pressure, it occasions no 
rise of pressure and no perceptible increase of amplitude of beat. 
When, however, the injection is made into a dog reduced to a 
state of shock by manipulation and chilling of the abdominal 
viscera there is an immediate rise of pressure. Quantitatively 
this rise depends largely upon the age and general condition of 
the dog (old dogs respond much less vigorously than do young 
ones) and also upon the degree of shock. In moderate shock the 
rise is much more pronounced than in the later stages. We con- 
sider a rise of 18 mm. (mercury manometer) to be an average 
effect, but it' was not uncommon for an injection to be followed 
by a rise of 40 mm. It was noted in analyzing om tracings that 
more significant than the sharp response to the injection is the 
steadiness with which the blood pressure climbs and maintains 
itself at a high level. We found in many instances that after the 
new level of pressure was established it required rough manipula- 
tion to reinduce the previous low level of shock pressure, and we 
believe that those dogs that received an initial injection of sodium 
bicarbonate before the abdomen was opened and while the pres- 
sure was at its normal height were reduced to a state of shock 
with more difficulty than those animals that did not receive an 
initial dose. Such a statement of course is difficult of proof be- 
cause of the varying resistance of different animals to the various 

manipulations we praetised, . 

Hand in hand with the rise of pressure went an increase oi 
amplitude of heart beat. This increase varied quantitatively as 
did the rise of pressure itself, its chief characteristic being its 
constancy. Not infrequently the amplitude of beat was doubled 



SEELIG, TIERNEY, RODENBAUGH: SODIUIM BICARBONATE 199 

imniediately after the injection of the bicarbonate, and the increased 
\ amplitude often persisted for half an hour or longer after the injec- 
\ tion of the solution. We were fortunate in encountering one dog 
I (experiment 16) that showed, an abnormally large amplitude of 
I beat before shock was induced. In this animal the amplitude 
1 of beat was 24 mm. In the state of shock the amplitude fell to 
I 15 mm., but following the injection of 25 c.c. of a molecular solu- 
I tion of sodium bicarbonate the amplitude rose to 21 mm. Like- 
wise in some animals very susceptible to manipulative procedures, 
with a normal low amplitude, in whom the cardiac weakness was 
so pronounced as to barely record any systolic-diastolic differences 
on the tracing the injection of the bicarbonate solution was immed- 
iately followed by an amplitude of beat measuring 3, 4, and 5 mm. 
This increase of amplitude, as we have pointed out in the case 
of the blood-pressure rise, is also well maintained over a fairly 
long period of time. One experiment (experiment 19) was par- 
ticularly instructive in demonstrating the contrasting effects of 
sodium bicarbonate and adrenalin, one of the stock antishock 
drugs. The immediate effect of the first adrenalin (1 to 5000) 
injection was to raise the blood pressure without influencing the 
low amplitude of beat; following the injection without an appre- 
ciable time interval the blood pressure fell to a lower level than 
before the injection, and at this level it remained. A second injec- 
tion of a stronger solution of adrenalin (1 to 1000) caused a more 
marked rise of pressure and a pronounced increase of amplitude 
lasting one minute, followed by a fall of pressure again to a lower 
level than before the injection and a diminution of amplitude to 
its previous small height of 1 mm. At this stage 50 c.c. of a mole- 
cular solution of sodium bicarbonate was injected and was followed 
by a well-sustained rise of pressure and by an increase in amplitude 
up to 4 mm. 

In all of these fifty experiments with sodium bicarbonate we 
could not determine any effect on the rate of heart beat. When 
the bicarbonate was administered before shock was induced the 
rate of beat was not quickened, and when it was administered 
during the period of rapid heart action incidental to shock the 
rate was not slowed. These facts tally with the results of Howell® 
in his study of sodium carbonate. 

In addition to its influence on the cardiovascular apparatus 
the sodium bicarbonate infusions exerted a marked effect on the 
respiratorj'^ function. The rate of respiration was sometimes 
increased, sometimes slowed, and sometimes unaffected. These 
variations did not seem to depend upon idiosyncrasies in the 
different dogs, for we observed all in the same dog following different 
injections of the same amount of the drug. The notable fact was 


• Loc. cit. 



200 SEELIG, TIERNEY, RODENBATJGH: SODIUM BICARBONATE 

that the depth of respiration was increased. This respiratory 
response which followed almost immediately upon the injection 
of the salt and persisted for a long period after the injection had 
been made was so pronounced as to attract attention by the marked 
thoracic movements and the deep sighing respirations. Graphic 
tracings were necessary merely as a matter of record. The explana- 
tion of the increased respiratory activity undoubtedly rests upon 
the influence of the excess of carbon dioxide upon the respiratory 
centre, for the respiratory phenomena observed after the injection 
of sodiuni bicarbonate were practically identical with those noted 
after the injection of pure carbon dioxide gas in later experiments. 
By using a marked excess of sodium bicarbonate solution the 
respirations could be made feeble and shallow, and for short periods 
even inhibited. 

Such then were the effects noted upon the cardiovascular and 
respiratory mechanisms, following the injection of small quantities 
(25 c.c.) of a molecular sodium bicarbonate solution: marked 
increase of blood pressure, the increase following immediately 
upon the start of the injection and being well sustained for var}'^- 
ing long periods; no influence upon rate of heart beat; marked 
increase of amplitude of beat, this increase likewise being well 
sustained over varying long periods of time; varying effects upon 
rate of respiration; constant effect upon depth of respiration, 
which was so increased as to be noticeable without the aid of 
tambour and drum. 

It seemed to be evident after the first experiment that the pressor . 
effect of sodium bicarbonate could hardly be explained on our 
a 'priori assumption that carbon dioxide was liberated intravascu- 
larly, thus replacing the gas lost as a result of shock (acapnia — 
Henderson). For, as we have already noted, coincidently with 
the rise of pressure following the injection of the bicarbonate 
there set in a period of marked and sometimes violent respiratory 
activity that induced a more thorough and prolonged ventilation 
of the lungs than we have ever seen caused by procedures planned 
to cause shock. If Henderson’s theory of acapnia were correct 
such ventilation ought to have deepened the shock of our animals 
(25 c.c. of our solution contained 2.1 gm. of carbon dioxide gas, 
which could hardly be a sufficient quantity to make up any marked 
deficiency in the blood) on account of the marked increase in respi- 
ratory activity and resultant pulmonary ventilation. Since there- 
fore the rise of blood pressure could not, with certainty, be explained 
on the basis of increased carbon dioxide content of the blood, we 
tried to determine what other factors might be discovered as pos- 
sible explanations of the pressor effect of sodium^ bicarbonate. 
We attacked the problem by the process of exclusion and took 
up in order the influence of (1) the bulk of fluid injected; (2) hyper- 
tonicity of the fluid injected; (3) alkalinity of the fluid injected; 



SEELIG, TIERNEY, RODENBAUGH: SODIUM BICARBONATE 201 

(4) influence of free carbon dioxide (intravascular) on the blood 

pressure. ^ , 

Bulk of Fluid Injected. It is unquestionably true that the 

intravascular addition of any appreciable quantity of fluid to a 
shocked animal will cause a rise of pressure. This rise is usually 
transitory and the transitoriness usually measures directly to the 
degree of shock. In the marked grades of shock the fluid escapes 
into the tissues (edema) about as rapidly as it is introduced into 
the vessel, and therefore causes slight or no rise of pressure. In 
order to avoid any confusion of interpretation, such as might arise 
from mere bulk of fluid injected, we always introduced amounts 
under 26 c.c. We are therefore in a position to state that the 
rise of pressure following our injections was not due to mere bulk 
of fluid. In a number of experiments we noted a distinct rise after 
the introduction of from 2 to 5 c.c. of a normal solution of sodium 
bicarbonate. In this connection one series of experiments fur- 
nished particularly interesting results: A given quantity of sodium 
bicarbonate (2.5 grams) was injected into the shocked animals 
in dilutions of 1 to 10 and 1 to 40. The animals that received a 
1 to 10 dilution (that is, 25 c.c.) showed the typical well-sustained 
rise already described, whereas those that received a 1 to 40 dilu- 
tion (100 c.c.) showed a much more pronounced initial rise follow- 
ing the iiijection, with a tendency to sustain the high level. The 
greater rise caused by the more dilute solutions can be attributed 
only to the excess of fluid (75 c.c.) introduced, for in both instances 
the quantity of sodium bicarbonate was the same. 

Influence of Hypertonicity. It has been demonstrated by 
numerous observers that in shock there is an escape of plasma 
from the bloodvessels into the tissues. This observation has been 
confirmed at autopsies and also by the determination of the specific 
gravity of the blood, which is heightened in shock as a result of 
concentration of the blood. It has even been suggested- that shock 
is due to increased specific gravity of the blood. If the current 
of the stream of liquid from the vessels toward the tissues could 
be reversed, or even stopped, the specific gravity of the blood 
would not be raised. It is possible that the introduction of a 
hypertonic solution might accomplish this purpose and that our 
sodium bicarbonate infusions might have been effective on this 
basis. That this assumption is not correct, however, we proved 
by the simple experiment of infusing shocked dogs with the hyper- 
tonic^ salt solution and with, hypertonic basic sodium phosphate 
^lutions, with^ practically no effect on the low blood, pressure. 
Dawson^ working with hj^pertonic sodium bicarbonate solution 
secured results identical with oius. 


* Loc. cit. 



202 SEELIG^. TIERNEY, RODENBAIJGH: SODIUM BICARBONATE 

Influence of Alkalinity. It is so natural to assume that 
any phenomenon following the use of an alkaline salt is due to 
alkalinity that we must guard against a 'post hoc error in logic in 
explaining the pressor effect of sodium bicarbonate on the basis 
of its being an alkaline salt. In order to determine the influence 
of alkaline salts on the low blood pressure of shock, we infused 
various dogs with small quantities (25 to 50 c.c.) of 0.1 per cent., 
0.25 per cent., and 1 per cent, of potassium hydrate in physio- 
logic salt solution, with half molecular solutions of basic sodic 
phosphate (Na2H.P.04), with half molecular , solutions of sodium 
carbonate, and with molecular solutions of the alkaline tribasic 
sodic phosphate. These experiments showed conclusively that 
alkalinity alone cannot explain the rise in pressure. Sodium car- 
bonate, for example, which is a much more strongly alkaline salt 
than is sodium bicarbonate, invariably gave a pronouncedly less 
marked rise of pressure. The basic sodic phosphate in most of 
our experiments gave no rise of pressure (this basic salt is in reality 
only slightly alkaline), and when a rise did occur following its 
use we were unable to determine positively that this rise was not 
coincidental rather than a casual result. The various solutions 
of sodic hydrate never caused a rise. The tribasic sodic phosphate, 
which is a strongly alkaline salt, caused only the slightest rise, and 
this rise was immediately followed by a fall that in two instances 
ushered in death. 

On the evidence at our command, therefore, we are obliged to 
conclude that the pressor effect of sodium bicarbonate does no 
depend solely upon the alkalinity of this salt. This conclusion 
is important in its bearing on the possible relationship between 
shock and acidosis, recently emphasized by Henderson. The 
problem of neutralization of acid by alkali substances in the blood 
is far from being as simple a problem as it is in vitro, as the follow- 
ing experiment demonstrates. By the introduction into the circu- 
lation gradually of a normal solution of acid sodic phosphate 
(NaH2Po4) the pressme may be influenced just as it is by shock, 
that is, it falls. If not too much of the salt is introduced the pres- 
sure rises again spontaneously, just as it does in a shocked dog 
that has not been too much compromised. By repeated small 
injections the pressure may be made to reach a stage where spon- 
taneous recovery does not occur and where to all intents and 
purposes (at least as far as manometric readings go) the animal 
is in a state of rather profound shock. The analogy between shock 
and acidosis seems on the face of it to be strong from this experi- 
ment. This analogy is further strengthened by the fact that the 
injection of a small amount of sodium bicarbonate immediately 
restores the blood pressure to a marked degree. Spiro® first out- 

8 Beit. 2 . lehre von d. Saurvergiftung bet Hunde und. Kananschen, Hofmeister Beit,, 1902. 
Band i. 


SEELIG, TIERNEY, RODENBATJGH: SODIUM BICARBONATE 203 

lined this experiment as an example of alkaline neutralization of 
an acid intoxication, and Jacoby® considers the experiment as 
an evidence of entgiftung’^ or neutralization of poisonous acid 
salt by an alkali. We. were able to confirm in detail the experi- 
ments of Spiro, but additional experiments performed by us did 
not point conclusively to the fact that the rise of pressure follow- 
ing the infusion of sodium bicarbonate was solely due to the 
alkalinity of this salt. For example, if acidosis were induced by 
infusing the acid sodic phosphate until a steady low blood pressure 
was reached the pressure could not be raised by instilling 0.25 
to 1 per cent, solutions of sodic hydrate; the introduction of the 
basic sodic phosphate also had practically no effect, and the intro- 
duction of the tribasic sodic phosphate was followed by a rise of 
pressure not comparable either in degree or in duration to that 
seemed by injecting sodic bicarbonate. Of course, this phase 
of the problem is fogged by the element of the toxicity of both 
sodic hydrate and the tribasic phosphate; but, nevertheless, we 
feel safe in assuming that in these acidosis experiments the pressor 
effect of sodic bicarbonate cannot unquestioningly be referred to 
its alkalinity alone. 

At this point we were forced in spite of our fears of gas emboli 
to test out the -possible blood pressure raising effect of carbon- 
dioxide gas supplied directly to the blood in shock. Our first 
experiment demonstrated that we could, with safety, introduce 
carbon-dioxide gas directly into the femoral vein from a Kipp 
generator. A detailed study of the physiologic effects of the 
intravascular injection of carbon dioxide will be made in a subse- 
quent report. It will suffice here merely to say that by properly 
regulating the flow of gas we could administer it over an indefinite 
period of time, and that although the administration stimulated 
the respiratory function most actively it did not influence the 
rate of heart beat, amplitude of pulse pressure, or height of blood 
pressure. When the carbon-dioxide gas was administered before 
shock was instituted it had no influence in warding off the oncom- 
ing fall of pressure, and when administered during shock it like- 
wise had no influence in restoring pressure toward a normal level. 
It would seem to be clearly established therefore both that the 
pressor effect of sodium bicarbonate does not reside in the carbon 
dioxide radical, and that shock itself cannot be referred to acapnia. 

The direct vasomotor effect of the sodium bicarbonate solution 
upon the bloodvessels we have not tested out. Howell,!® in his 
work upon sodium carbonate (a salt which, as we have seen, is 
closely allied to the bicarbonate in its action) says: “It is impos- 
sible from the experiments to state positively whether or not the 

• M, Jacoby , Einfahrung in d. Exper, Therapie, Berlin, 1910, verlag Julius Springer. 

Loc. cit. 



bassler: the diagnosis of chronic appendicitis 

alkaline injections had any effect upon the tone of the peripheral 
arteries, but the impression that I have obtained from a study of 
the records is that they act solely as a stimulant upon the heart 
and that the increased arterial pressure was due chiefly if not 
entirely to a more vigorous heart beat.” 

Since none of the factors of bulk, hypertonicity, alkalinity, or 
free carbon-dioxide gas showed itself the sole cause of the pressor 
effect of sodium bicarbonate, we were forced by exclusion to assume 
that this salt acts specifically upon the heart muscle. This assump- 
tion receives corroboration from the fact that with both vagi cut, 
and even with all the higher cerebral centres destroyed by Jackson^s*^ 
method, an injection of sodium bicarbonate is followed by a rise of 
blood pressure. 


PINCHING THE APPENDIX IN THE DIAGNOSIS OF 
CHRONIC APPENDICITIS. 

By Anthony Bassler, M.D., 

PROFESSOR OF CLIMCAL MEDICINE, NEW TORE POM'CLINIC MEDICAL SCHOOL AND IXOSPITALf VISIT- 
ING PHYSICIAN, NEW YORK POLYCLINIC HOSPITAL; CHIEF GASTRO-ENTEROLOCIST, GERMAN 
POLIKLINIK; visiting OASTRO-ENTEROLOOIST, people’s HOSPITAL, NEW YORK. 

Nothing in medicine in the way of examination seems to have 
been better learned than McBurney’s point and its significance 
in connection with the diagnosis of appendicitis. It is rare indeed 
among the students of my postgraduate teaching experience to ask 
the question “What is McBurney’s point?” and not receive an 
intelligent and capable answer. There is no doubt that the sign is 
of much value in the diagnosis of appendicitis, but that it fails at 
times is the purpose of this article. 

In the average case of pain in the lower right quandrant of the 
abdomen, some rise in temperature, increase in the pulse rate, a 
spasm of the abdominal muscles over the area, and perhaps pain and 
tightening when the thigh is straightened on the pelvis, the diagnosis 
is easy. In these cases the area of tenderness upon pressure is so 
much larger than the area which corresponds to the appendix itself 
that pressure midway between the umbilicus and superior spine of 
the ileum in a backward direction serves the purpose. But there 
are frank cases, usually subacute or those with a small abscess, 
wherein the tenderness on pressure is lower than would correspond 
sharply to McBurney’s point. In the average person when the 
head of the cecum is in normal position, an inch or so above the 
brim of the pelvis, the base or length of the appendix is slightly 

” The Production of Experimental Cephalic Coma, Jour. Pharm. and Exper. Therapj, 1902, 
vol. iv. No. 1. 



basslbr: the diagnosis of chronic appendicitis 


outside or midway on the spine and umbilical line, and there are 
many individuals in whom the cecum is much lower, and in them 
pressure upon what is McBurney’s point may not elicit the ten- 
derness that would come from pressure lower down over what would 
then correspond to the site of the appendix. Tlois is particularly 
true in cases of chronic appendicitis where all that may be useful 
in the way of physical examination is a tenderness localized to the 
appendix. Not considering those cases that give a historj^ of 
recurring acute attacks, there are many with dyspeptic symptoms 
due to a diseased appendix, this usually being a chronic process 
in which this sign may be important to diagnosis. 

In this connection I desire to criticize the teaching of some of 
the surgeons that appendicular dyspepsia may exist, mth_ no 
tenderness in the appendix region. It is always fair to the patient 
that no diagnosis of chronic appendicitis be made in those cases, 
even when the dyspepsia symptoms have subsided after the ap- 
pendix had been removed, because it may be that the patient 
had fears of the appendix being the cause of the dyspepsia and the 
removal of it acted autosuggestively in a favorable way upon the 
dyspeptic symptoms. I believe that an appendix must be tender 
before it can be of significance in causing dyspeptic symptoms. 

In the diagnosis of chronic appendicitis we must take into con- 
sideration the conditions of Lane’s kink, Jackson’s, and firmer 
membranes of the cecum, together with some less well-known 
conditions, such as insufficiency of the ileocecal valve, chronic 
excessive intestinal putrefaction causing a tender cecum, mainly 
at its head, and states connected with the ovary or extracecal 
structures. 

Taking cases with a history of chronic disorder in which more 
or less distress exists in the right iliac fossa, diagnosis of the 
above-mentioned states can only be made as follows: Lane’s 
kink by radiographs taken when the bismuth has reached the 
ileocecal region, these being made with the patient Ijdng on the 
left or right side and preferably in Trendelenburg’s position. The 
same is true of Jackson’s and firmer membranes of the cecum 
wherein the mobility of the cecum can be studied by the .T-rays 
and the presence of a membrane suspected. In addition to that 
a careful study of the bacteriology of stools with reference to their 
anaerobic content suggests the cause of membrane formation, for 
Jackson’s membrane is a protective process in which the endothe- 
lium of the peritoneum is raised by a hyaline subendothelial 
substance, vascularity of the membrane taking place as a nutritive 
process. Further, the double-barrelled colon is usually accompanied 
by these membranes. 

Insufficiency of^ the ileocecal valve can only be diagnosticated 
by the a:-rays, with a fluid bismuth suspension being introduced 
per rectum. The tender cecum due to chronic excessive intestinal 



bassler: the diagnosis of chronic appendicitis 


putrefaptioD is diagnosticated by a careful study of the stools 
and urine. This means the establishment of the patient on a 
known diet and the recording of the quality and quantity of 
foods for several days. Then careful and complete analyses of a 
twenty-four hour collection of urine and specimens of stool must 
be made, carrying the first through the sulphate partition, estimat- 
ing the oxalic and uric acids, and so forth, and the second through 
the fermentation and putrefaction tests, as well as through the 
products that such feces manufacture during these tests, with a 
careful study of the bacteriology. 

Conditions of the right ovary can usually be excluded by bi- 
manual palpation, provided one is careful in palpating the ovary 
between the fingers, causing it to slip about on the end of the inter- 
nal finger. Inflamed or diseased ovaries are tender upon pressure. 
After the tenderness of the ovary has been elieited the external 
hand makes pressure at right angles away from the ovary to the 
lateral wall of the pelvis and in a backward direction toward the 
appendix. In a simple case it will then be noted that no tenderness 
exists beyond the ovary. 

As was stated before, the appendix may occupy any position 
from the line drawn from the umbilicus to the anterior superior 
spine downward to the brim of the pelvis. It is logical that pressure 
upon McBurney’s point in an appendix that is chronically diseased 
and located below it will not elicit the tenderness that pressure 
below the point would, and if the subject be a female, one is liable 
to make the mistake and think that the right ovary is at fault. 
For the purpose of helping to differentiate this on abdominal 
examination alone a little extra consideration is required. 

Covering the majority of cases met with clinically and in thin 
subjects a point midway between the anterior superior spine and 
the umbilicus falls inside of the right edge of the rectus on that side. 
In the general run of cadavera if a long needle is driven down from 
this point and then dissection made it will be found that its course 
corresponds to inside the cecum, considering the cecum on a curved 
vertical line. In some, in the prone position it is directly over 
the cecum. Now in these when one makes pressure directly back- 
ward, as is done in obtaining McBurney’s tenderness, one is liable 
to press inside of the cecum or upon it and not over the appendix. 
In a number of appendices that I have had removed I have found 
the following plan to be decidedly more successful. 

If the patient is not too stout the lower border of the cecum is 
percussed for from Poupart’s ligament upward. Fortunately the 
cecum is usually distended with gas and an accurate level or 
cecum when the patient is on the back can be determined. Mter 
this is noted, percussion transversely across the cecum, is made 
to obtain its outer and inner edge. The outer edge is always 
possible of being noted. In percussing for this it is necessary when 



bassler: the diagnosis of chronic appendicitis 

on the outer edge that the percussion stroke be directed straight 
backward toward the lateral edge of the body, and when on the 
inner, directlj'’ backward toward the junction of the psoas and 



N/.. 








^ "'v-- . ‘ 

fri 

i>-< yy. -i:;; 


Pinching the Appendix. First shows pressure on a line midway betw’’een the umbilicus 
and the anterior superior spine of the ileum on the right side, the latter marked with a black 
dot. The second, the swinging of the thumb to the right of the patient, and pinching the 
appendix against the iliacus muscle. Patient viewed down the right side, head to the left 
of photograph. 


iliacus muscles at that area — these lines being more oblique than 
the outer edge of the rectus. With an estimation of about where 
the appendix would be as judged from the location of the lower 
end and sides of the cecum, pressure on the abdomen should be 



208 MUSSER; EFFECTS OF EXTRACT OF PITUITARY GLAND 


made at that point. When the cecum cannot be mapped out by 
percussion or the subject is well developed, and even in all, the 
second plan is to note the position of the right edge of the rectus 
muscle on the umbilical-spine line maintaining the site with a finger. 
Having the patient rise to a sitting position helps in palpating 
for the rectus edge. Standing at the right and facing the patient 
(for right-handed individuals) the thumb is placed vertical on the 
abdomen, the tip of the thumb pointing to the ensiform, when it 
is slowly pressed backward into the abdomen, not inward, outward, 
up or down. When the thumb has been sunlc about half-way down 
to the back of the abdominal cavity, it is swung to the right of 
the patient at a right angle to the downward pressure line. This 
.pinches the appendix against the iliacus muscle and unyielding 
structures under and at the side of it, and usually elicits pain or 
tenderness. It is w^ell, having done this in the mid-distance between 
the anterior superior spine and the umbilicus and not having 
obtained tenderness, to move the thumb down about one-half inch, 
performing it again, and so on downward until one has reached 
almost to the brim of the pelvis. The same procedure on the left 
side serves as a control. By means of this method of downward 
and then right lateral pressure it is possible to elicit tenderness 
in the average case of chronic appendicitis. When tenderness is 
obtained on transverse pressure to the left it may be a Lane’s 
kink, and when below it may be a tender ovary instead of an 
appendix. 


THE EFFECTS OF CONTINUOUS ADMINISTRATION OF 
EXTRACT OF THE PITUITARY GLAND. 

By John H. Musser, Jr., M.D., 

PBTSICIA^' TO THE MEDICAL DISFENSART OF THE HOSPITAL OF THE HNIVEESITT OF 
PENNSTLVAHIA : ASSISTANT PHYSICIAN TO THE PHILADELPHIA GE.VERAL 
HOSPITAL AND THE PRESBYTERIAN HOSPITAL, PHILADELPHIA, PA. 

The present investigation w’’as undertaken in order to study 
more particularly the eft’ect of pituitary extract upon the blood 
pressure when administered by the mouth over a more or less 
prolonged period, but also, at the same time, to observe other 
phenomena w^hich might be attributed to the employment of the 
drug. 

The effect of intravenous or hj'podermic injections of prepara- 
tions of the pituitary gland upon the blood pressure has been studied 
b}'’ numerous observers, and the gland has been given^ by mouth 
for long periods in the treatment of infantilism; but in the first 
case the observations were only taken for a comparatively short 
time, and usually after one large or several frequently repeated 
doses, and in the' latter case no systematic studies have been made 



MtrSSER; EFFECTS OF EXTRACT OF PITUITARY GLAND 209 

of the effect of the prolonged use of the gland upon the blood 

pressure. ... 

Various observers have shovni that injections of extract of the 
infundibular portion of the pituitary gland cause a rapid and pro- 
nounced rise in blood pressure, which persists for a variable time, 
usually much longer than that produced by adrenalin, and which 
is due to the constriction of the peripheral arteries. Repeated 
injections, however, result in a less marked rise in the blood pressure 
after each injection until finally a fall in pressure occurs. Various 
theories might be employed to explain this fall: 

1. That it is due to a saturation of the blood, with pituitary 
extract, “so that an interaction takes place wliich converts its 
constricting action on the peripheral vessels into a dilating one.”^ 

2. That it is due to a late depressing action influencing the 
strength of the cardiac beat.^ 

3. That it is due to the action of the depressor substance vRich 
the gland contains overpowering the pressor substance, causing 
a dilatation of the peripheral bloodvessels.® 

4. That it is due to the central dilator effect of the drug.^ 

5. That there is an inhibitory substance present, preventing a 
secondary action of the drug.® 

Of these theories the first and second seem most tenable. It is 
therefore plausible to attribute the secondary depressor effect of 
the drug to the larger quantity that is necessary to produce this 
result. Similar effects are noted vdth some other drugs which in 
average dose will produce certain result, while larger, not neces- 
sarily lethal doses, will cause a result contrary to the initial finding. 
In giving fair-sized doses of the glandular extracts by the mouth 
the overwhelming action of the larger doses is thus obviated and 
the effects are largely those that result from its primary action. 
Aside from the action of the infundibular portion of the gland upon 
the vascular system, several other effects may be observed; thus 
it has been noted that persistent use of lager doses may cause 
glycosuria; after single and repeated intravenous injections diuresis 
occurs; frequently there is a slovdng of the pulse rate, perhaps 
associated with a decrease in the amplitude of cardiac contractions; 
possibly an inhibition of the flow of pancreatic juice; and usually 
stimulation of the uterine and intestinal musculature. Clinically, 
the infundibular portion of the pituitary gland has been extensively'' 
employed as an oxytoxic, occasionally as a diuretic. It has given 

' C. P. McCord, An Investigation of the Det'ressor Action of Pituitary Extracts. Arch. Int. 
Med., 1911, viii, 609. 

* C. J. Wiggers, The Physiology of tac Pituitarj' Gland and tUe Actions of its Extracts, Auer. 
Jour. Med. Sci., 1911, c.xli, 502. 

’ Schafer and Vincent, The Physiological Effects of the Pituitary Body, Jour. Phys , 1899- 
1900, XXV, 87. 

* T. SoUman, and J. I. Pilcher, Central Vasomotor Effects, Jour. Pharm. Exp. Therap., 1910, 
It 571. 

‘ W. W. Hamburger, The Action of Intravenous Injections of Glandular Extracts and other 
‘Substances upon the Blood Pressure, Amer. Jour, 1904, xi, 282. 



JIUSSER; effects of extract of FITmTARY GLAND 

good results as a vasoconstrictor when employed in the treatment 
of shock and other conditions associated with transient low blood 
pressure. It has also been used in many other less relevant con- 
ditions. Extracts of the whole gland have been used in the treat- 
ment of both acromegaly and infantilism. 

In the follovung series of patients the first few were selected 
for observation because they had showed persistent low blood 
pressure upon repeated examination; later, patients showing higher 
pressures w'ere also given the glandular extract. In all, observa- 
tions were made upon 18 people, 13 of wEom were patients in the 
dispensary of the Hospital of the University of Pennsylvania, 
and 5 of whom W’ere medical students who volunteered to assist 
in the investigation. The extract wms given over a period of from 
one week to ten months without other medication. The 5 students 
took the extract for only a week, but it was administered to all 
the patients for at least a month unless stopped on account of some 
untoward effect. The preparation employed wms the extract of 
the whole gland made up in 0.2 gram tablets containing 0.065 
gram of the dried gland, equivalent to 0.26 gram of the fresh gland. 
The dosage at first W'as two of these tablets twice a day, but no 
effect wms noted until the dose wms increased to one tablet four 
times a day. Larger doses wmre given to several individuals^ but 
soon discontined. 

Although most observers have agreed that the posterior lobe or 
infundibiilar portion of the gland elaborates the secretion that 
acts upon the bloodvessels, nevertheless in a recent work, D. Lewis, 
J. L. hliller, and S. A. Matthews'^ found that extracts of the pars 
intermedia caused a decided rise in blood pressure, the extracts 
of the pars nervosa also caused an eventual rise in the pressure, 
as did likewise in the majority of instances, extracts of the anterior 
lobe. They believe that the pressor substance is secreted by the 
pars intermedia and those cells of the anterior lobe which bound 
the cleft. It therefore seemed feasible to employ the wEole gland 
not only because of the impossibility of securing preparations 
containing only the pars intermedia, but also because the dried 
extract is more suitable to prescribe to dispensary patients. 

The blood pressure w^as taken one or more times before gmng 
the pituitary tablets, and then later at each subsequent visit to 
the dispensar^^ until the observations W'ere discontinued. The 
blood-pressure readings were all taken twm or more hours after 
ingestion of the glandular extract and after half-hour or more rest 
in the dispensary. The readings wmre made by the auscultatory 
method, systolic" and diastolic pressure being recorded w^hile using 
a Stanton sphygmomanometer. 

Patient 1. — The glandular extract caused a rise m pres^re 
from 12 to 20 mm. of mercury in all the many observations. Ihe 

» The Effectson Blood Pressure of Intravenous Injections of Extracts of tUe I arious Anatomic 
Components of the Hj-popbyris. Arch. Int. Med., 1911. vii, 7S5. 



musser: effects of extract of pituitary gland 211 

pulse pressure showed but little variation. The pulse rate averaged 
consistently about 80 beats per minute, except at one time when 
it fell to 60, after taking larger doses, six tablets a day, for several 
days. This larger amount also caused diarrhea. Twelve days 
after cessation of treatment, pressure showed but slight change, 
in nineteen days it had returned to its former level. 

Patient 2. — ^The systolic pressure increased 18 mm. of mercury. 
The diastolic pressure was unchanged. Diuresis was observed. 

Patient 3. — The systolic pressure was increased from 9 to 20 
mm. at different observations. The pulse pressure was unchanged. 
A slowing of the pulse rate — 60 per minute — was also noted for a 
short time. At one time during the experiment the patient stopped 
the drug for six days without any effect on the blood pressure. 
Eight days after the complete cessation of ingestion of the glandular 
extract the systolic pressure had returned to within 8 mm. of 
mercury of the average pressure before the experiment, and in 
thirteen days had fallen back to the previous average pressure. 

Patient 4. — ^The systolic pressure increased 8 to 10 mm. at 
various observations. The pulse pressure remained unchanged. 
Patient 5. The increase of systolic pressure varied between 

12 and 18 mm. The pulse pressure was unchanged, and the pulse 
rate was variable. 

Patient 6. — ^The increase in systolic pressure varied between 

13 and 20 mm. The pulse pressure before taking the gland was 
35; during its administration it was between 45 and 65, and the 
pulse rate averaged 86. 

Patient 7. — ^The systolic pressure increase averaged 16 mm. 
The pulse pressure was unchanged. Diarrhea developed after 
taldng the gland extract for two weeks, and it was therefore dis- 
continued. 

Patient 8. — ^This patient suffering udth chronic nephritis and 
low blood pressure was one of the few patients decidedly improved 
by the action of the gland. The systolic pressure estimated several 
times before taldng the preparation never exceeded 105 mm. of 
mercury. It rose a short time after the use of the extract to 112; 
two days later it rose to 120, and henceforth varied between 120 
and 125. The diastolic pressure rose synchronously with the 
systolic. The secretion of urine was decidedly increased, according 
to the report of the patient, and the subjective symptoms were 
also markedly alleviated, so that he felt better than at any time 
during the past several years. The pulse rate also showed an 
increase, rising from 64 to 92 beats per minute. One week after 
discontinuation of the drug the pressure was 115 and in two weeks 
back to 105. 

Patient 9. ^This patient, with a more elevated pressure than 
the majority of the individuals studied, showed in nine days an 
increase in pressure equal to 27 mm. of mercury, the pressure 



212 musser: effects op extract of pituitary gland 

rising to 155 systolic and 90 diastolic. The pulse rate increased 
to 106. The pituitary extract was immediately stopped. 

Patient 10.— This patient showed an increase of systolic pres- 
sure of 20 mm., but as a severe diarrhea developed the treatment 
was discontinued. 

Patient 11. — The systolic pressure was increased, the increase 
ranging between 12 and 20 mm. of mercury. The pulse pressure 
ratio remained unchanged. Two weeks after cessation of the 
drug the systolic pressure had returned to previous figures. 

Patient 12. — ^The increase of systolic pressure varied between 
15 and 20 mm. of mercury. The diastolic pressure did not show 
a corresponding increase. The pulse rate wms also increased, 
averaging about 95 beats per minute. Two days after stopping 
the drug the systolic pressure was down 5 mm. In twelve days 
it was 5 mm. higher than before starting the experiement. Eighteen 
daj'’s it was approximately at the same level as at the beginning 
of the drug treatment. 

Patient 13. — The blood pressure increased from 123 systolic 
(70 diastolic) to 135 systolic (80 diastolic) in twelve days, when 
the treatment wms stopped on account of diarrhea. The pulse rate 
increased 15 beats per minute. 

Subsequent observations after discontinuation of pituitary 
extract in these patients show’ed a tendency for the pressure to 
return to its previous level after a lapse of about two weeks. This 
fall occurred gradually so far as could be determined. 

Five students took the glandular extract for a week. Four 
showed a rise in systolic pressure of 4, 10, 15 and 17 mm. of mercury 
respectively without a corresponding rise in diastolic pressure. 
One showed no change in the systolic or diastolic pressure. In 
two of these men no change in the pulse rate occurred, wdiile in 
the other three there was an increase of 10, 10, and 20 beats per 
minute. Three noted diuresis; the two that did not note this effect 
had a rise of 4 and 17 mm. respectively. One man had a slight 
diarrhea, while 2 had a severe diarrhea, which was wmrse in the 
man whose pressure went up the most. Examinations of the urine 
of the IS patients were made, and at no time wms sugar demonstrated 
by Fehling’s test. _ _ 

Recapitulation. Eighteen individuals were given the dried 
extract of the whole pituitary gland without other medication. 
The follovdng effects were noted: 

1. Blood pressure: Seventeen showed a rise in systolic blood 
pressure, the greatest rise being 28 mm. of mercury. Usually a 
corresponding rise in diastolic pressure occurred, though rarely 
it remained at the same height as before taking the extract or even 

became lower. . 

2. Pulse rate; The changes in the pulse rate were inconstant ; 
an increase was generally observed, though in 2 indndduals the 
rate was decidedly decreased. 



c ashman: tuberculin therapy in surgical tuberculosis 213 

3. Diuresis: Six individuals noted a diuretic effect. The extent, 
absence, or presence of this symptom could not be accurately 
determined. The urine showed no particular change except in 
one case (8). Glycosuria was never observed. _ 

4. Intestinal tract; Diarrhea developed in 7 cases, and 4, 
previously costive, had daily movements during the period of 
taking the drug. 

5. Subjective symptoms; Four individuals were apparently 
much benefited by the rise in pressure and general stimulative 
effect of the glandular extract upon the unstriated muscle, and 
one person was benefited through the diuretic effect of the extract. 
In the remaining patients there was little effect noted except by 
those who developed the rather annoying diarrhea. 

Conclusion. Prolonged administration of extracts of the 
pituitary gland exert a distinct pressor effect upon the peri- 
pheral vascular apparatus, which persists for an appreciable time 
after discontinuation of the drug. This is apparently the only 
consistent affect following continued administration of the gland 
per oram; other results are variable and indefinite. 


TUBERCULIN THERAPY IN SURGICAL TUBERCULOSIS, WITH 
THE CORRECT DOSAGE ACCURATELY DETERMINED 
BY THE CUTANEOUS REACTION. 

By B. Z. Cashman, M.D., 

LAYAl'ETTB, INDIANA. 


In 1910 IVhite and Van Norman^ reported a method of deter- 
mining, by means of a cutaneous reaction, the correct therapeutic 
dosage of tuberculin for subcutaneous injection. The method 
was adopted in the surgical and gynecological wards of St. Francis 
Hospital, Pittsburgh, and has been followed in the treatment of 
twenty-eight cases of surgical tuberculosis. A more recent article'-' 
by the same writers confirms their previous work. 

Starting with the theory that much of the benefit derived from 
tuberculin therapy is due to the reaction on the part of the body 
cells produced by tuberculin rather than to an induced tolerance 
to it, the method is based on the variation in susceptibility of 
different individuals to the action of tuberculin on the skin and 
when injected into the tissues. The optimum dose, as determined 
by this method, is the quantity of tuberculin required to produce 
the greatest local, general, and focal reaction without producing 
consitutional s;>Tnptoms, such as rise of temperature, malaise, and 
other evidences of overdosage. 

The dose for each individual is determined according to that 


‘ Arch. Int. Med., 1910, vi, 449. 


* Ibid., 1912, ix, 114. 



214 CASmiAN; tuberculin therapy in surgical tuberculosis 

individual’s susceptibility to tuberculin as shown by the cutaneous 
reaction, and^ treatment is begun with this optimum dose instead 
of starting mth a very small arbitrary quantity of tuberculin and 
gradually increasing the dosage in order to produce a tolerance, 
as is commonly done in the various methods of tuberculin therapy 
in vogue today. By the new method the treatment is begun mth 
larger quantities of tuberculin, a longer interval is allowed to elapse 
between doses, and no effort is made to produce a tolerance. In 
this way treatment may be continued for months without necessity 
for changing the dosage. 

In our cases tuberculin was used as an adjunet to the usual 
hygienic and dietetic measures such as rest, fresh air, sunshine, 
and nourishing food. Sinuses were treated locally, with tincture 
of iodine or with injections of Bismuth paste. In cases with joint 
involvement, fixation and extension were employed. Operative 
treatment was conducted when thought to be indicated, and tuber- 
culin was used after incomplete removal of diseased tissues. In 
children, operative procedures were limited as much as possible, 
and consisted chiefly of incision or aspiration of abscesses, and 
curettement of sinuses. The majority of the cases of tuberculous 
adenitis in children presented sinuses or broken-down fluctuating 
glands, which were incised. These patients were treated with 
tuberculin without removal of the glands. As a rule, tuberculin 
was not given in cases with temperature above 100°. The hospital 
patients were treated outdoors, and confined to bed during the 
febrile period of the disease. Manj'^ of the afebrile cases were treated 
in the out-patient department, with instructions as to their mode 
of life at home. 

The cases were treated until all symptoms disappeared and 
they were apparently well. An effort was made to continue with 
the administration of tuberculin for months after there was apparent 
cure, and this was done in a few of the cases; but in the majority 
of instances the patients failed to return for further treatment 
after the disappearance of signs and symptoms. 

The diagnosis of the cases was based on the clinical histop'^, 
physical examination, tuberculin test, x-ray pictures, negative 
bacteriologic findings in cases with pus which had not been exposed 
to secondary infection by the spontaneous rupture of the abscess, 
and was confirmed in a large proportion of the cases by microscopic 
examination of the tissues removed. The Wasserinann reaction 
was used in some of the cases to aid in excluding sjqihifis, especially 
in those cases showing multiple bone lesions. 

Technique. ViTite and Van Norman® showed that the quantity 
of tuberculin required to produce a reaction of 4 mm. on the skin, 
their so-called “minimal cutaneous reaction,” wnll, when injected 
intradermically, produce a local reaction at the site of injection 
2 to 5 cm. in diameter. They consider this quantity tome toe 

* Loc. cit. 



cashman: tuberculin therapy in surgical tuberculosis 215 

optimum dose— that is, the dose that will produce the most marked 
reaction without producing constitutional symptoms.^ For deter- 
mining this dose the technique employed in this series has been 
practically that advocated by the originators of the method, with 
a few minor exceptions. 

The tuberculin used was. Koch’s O. T., in various dilutions. 
In addition to this a von Pirquet scarifier, a pipet which measures 
c.c. of the tuberculin dilution, and shields for the protection 
of the site of the sldn test were used. For the latter purpose 
lids of pill boxes, secured in place by strips of adhesive plaster, 
were found to be sufiieient. 

On the mesial anterior surface of the forearm the skin is cleansed 
with ether, and two points, about one inch apart, are scarified by 
a rotary motion of the scarifier until sufficient epidermis is removed 
to leave a pink base from which neither blood nor serum exudes. 

These scarified areas measure 2 mm. in diameter. The lower 
area is used as a control, while on the upper area there is placed 
yq-o c.c. of the tuberculin dilution, the shield is applied and the 
patient is instructed to hold the arm horizontally until the solution 
dries, which requires twenty to tliirty minutes as a rule. The 
shield is worn until the first reading is made. The readings are 
made in twenty-four, forty-eight, and seventy-two hours after 
the tuberculin is applied, and the area of redness and swelling is 
measured in millimeters. 

Since many of the minimal cutaneous reactions (4 mm. in 
diameter) occur with dilutions near 1 per cent, this dilution serves 
as a good working basis with which to begin, and thereafter weaker 
or stronger solutions can be used according to the size of the reac- 
tion obtained. For example, if c.c. of 1 per cent, tuberculin 
produces a reaction 6 mm. in diameter in forty-eight or seventy- 
two hours, weaker solutions as ^ per cent, or J per cent, should be 
used until a 4 mm. reaction is obtained. The quantity of tuberculin 
in tot c.c. of the dilution used to produce the 4 mm. reaction, which 
quantity, in the case of 1 per cent, tuberculin, would be teew gm-, 
or tV nag., is the optimum dose. This quantity, when injected 
into the skin, should produce a local reaction 2 cm. to 5 cm. in 
diameter at the site of the injection, which local reaction serves 
as a control of the test. 

The therapeutic injections were given into the arm every two 
weeks. No effort was made to inject the tuberculin with reference 
to the lymphatics in the region of the tuberculous focus, as suggested 
by White and Van Norman. 

Remarks on Technique. — ^Until one becomes accustomed to 
reading the skin reactions it is well, after first obtaining the 4 mm. 
reaction, to repeat the test with a weaker solution. For example, 
if a 4 mm. reaction is obtained with 1 per cent, solution the test 
should be repeated with per cent, solution, and if the previous 
reading was correct the size of this last reaction should be less than 



216 CAsmiAN: tuberculin therapy in surgical tuberculosis 


4 nun. in diaincter. ^Vliite and Van Norman advise waiting three 
or 4 days between each skin test, and one week after the last skin 
test before injecting the therapeutic dose. We have, up to the 
present time, experienced no untoward results with the method, 
although we have repeated, the tests as soon as the readings were 
made, thus shortening the time required for estimating the optimum 
dose. Two or tlnree tests are usually sufficient. 

Our dilution for therapeutic injections were made so that | c.c. 
contained the desired quantity of tuberculin, thus making a- con- 
stant bulk of solution for injection in every case. 

As the injection into the sldn is more painful than into the sub- 
cutaneous tissues we have been injecting only the initial dose into 
the skin. This is done in order to determine the size of the local 
reaction, which we use as a control of the skin test. The subsequent 
injections of tuberculin were made into the subcutaneous tissues, 
except that ever^'- two or tliree months we injected again into the 
skin to note whether the size of the local reaction had changed, 
thus determining whether it was necessary to repeat the skin test 
and estimate a new dose. We haAm not found it necessary to change 
the dosage in any of our cases which were treated uninterruptedly. 
Although some of them were treated over a period of months the 
local reaction at the site of injection did not vary in this beyond 
the limits of 2 cm. and 5 cm. 

That susceptibility to tuberculin does change was shown in 
our cases of tuberculous peritonitis, especially when rapid and 
marked improA^ement took place after operation. Vffiile these 
cases responded mildly to the Amn Pirquet test before operation, 
their rapid improvement after operation was accompanied by a 
marked increase in the intensity of the reaction to the test. If the 
dose of tuberculin had been estimated and injected before operation 
we are unable to say AAffiether this change in susceptibility after 
improAmment took place would haA'^e necessitated a change in dosage, 
as treatment was begun in our cases after operation and not 
until the patient^s temperature had fallen to below 100°, and the 
general condition was much improved as a result of operation. 

For measuring xiir c.c. we use a capillary pipette. One one- 
hundredth gram of distilled water is weighed on a chemical balance; 
this quantity of fluid readily passes up the tube by capillary attrac- 
tion and the upper level is marked. A rubber tube, such as is 
used on a blood pipette, is attached to the capillary pipette, 
and with this the tuberculin can be accurately transferred to the 


scarified area, . i i f 

The dilutions of tuberculin are made on, the basis that 1 c.c. or 
Koch’s 0. T. contains 1000 mg., or 100 per cent, of tuberculin. 
From tliis, weaker solutions are made with normal salt solution 
containing 0.25 per cent, phenol. Fresh solutions are made up 
every tAAm months, and are kept on ice. We keep the following 
dilutions for the skin test, viz: 10 per cent., 1 per cent,, and U.l per 



CASHIMAN: TUBERCULIlSr THERAPY IN SURGICAL TUBERCULOSIS 217 

cent., and from these 3 per cent, or 0.5 per cent, or any required 
dilution for the skin test can be made. The solutions for thera- 
peutic injection are made so that ^ c.c. contains the desired quantity 
of tuberculin. Por example: 

(a) 1 c.c. of 0.1 per cent, solution plus 9 c.c. diluent — | c.c. 
contains 0.00005 gm. of tuberculin. 

(b) 1 c.c. of (a) plus 9 c.c. diluent — | c.c. contains 0.000005 gm. 

(c) 2 c.c. of 0.1 per cent, solution plus 9 c.c. diluent — f c.c. 
contains 0.0001 gm. 

(d) 1 c.c. of (c) plus 9 c.c. diluent — | c.c. contains 0.00001 gm. 

In this way any dilution can be readily made. 

Results. — ^There were twenty-eight cases treated in this series, 
consisting of tuberculosis of the kidney and ureter, peritoneum, 
bones, joints, glands, and skin, as follows: 


1 

Case I 
No. 1 

1 

Age. { 

1 

i 

Tuberculosis of i 

i 

1 1 

i 

29 I 

Kidney and ureter j 

18 1 

20 

Peritoneum , 

4 i 

1 

46 

i ' 

Peritoneum and pleura ' 

1 1 

1 

16 

1 3 

1 Inguinal glands j 

23 

1 


; Axillary glands ! 

1 ; 

i 

19 1 

: 1 

^ ^ i 

1 

Cervical glands ! 

20 

23 i 

Cendcal glands 

26 

16 

j Cervical glands ' 

27 

3 

, Cervical glands i 

9 ! 

26 

Cervical glands ^ 

12 

17 

Cervical glands ' 

13 

1 18 

i 

' Cendcal glands } 

22 

1 29 

1 

Cervical glands and | 
j lungs : 

Cervical glands and | 
1 hip j 

15 

2 

28 

: ^ 

Cendcal and inguinal i 
glands 1 

10 

1 7 

1 

Cendcal glands and | 
1 bones (multiple) 

11 

1 

' Bones (multiple) i 

1 1 

14 

i 7 

Bones (multiple) ] 

6 

1 35 

1 Bones (vertebne) ; 

3 

1 16 

Hip ' 

25 

. 10 

, Hip i 

t 

5 

42 

i Hip 

8 

6 

, Hip 

24 

2 

1 Knee 

2 

39 

Ankle 

7 

' 5 

' Ankle 

17 

1 30 

1 Elbow 

21 

i 16 

1. 

1 Skin 

* 1 


VOI.. 

146» NO. 2.— -AUGUST, 


Operation. 


Dose, 

grams. 


1. Incision of abscess 

2. Nephrectomy 
Laparotomy: double 

salpingectomy 

1. Thoracentesis; 
paracentesis 

2. Laparotomy; ap- 


pendectomy 
Noi 


one 

None 


None 

None 


i None 

Incision of abscess 

Excision of glands 
(incomplete) 

Excision of glands 
(incomplete) 

None 

Aspiration of abscess 
— hip 

Incision of abscess — 
neck 

Incision of abscess — 
neck and curetment 
of bone sinuses 

Curetment of sinuses 


Curetment of sinuses 

Laminectomy 

None 

None 


Incision of abscess 
Aspiration of abscess 
None 

Arthrotomy and cu- 
retment 
None 

Resection of joint 
None 


.000005 

.0005 

.0001 


.00001 

.00002 


.00005 

.0001 

.00001 

.00002 

.00005 

.00001 

.000005 


.0001 

.000005 

.00002 

.00001 

.000005 


.00001 

.00005 

.00015 

.00005 


.00005 

.00005 

.00005 

.00005 

.00001 

.00005 

.00001 


Duration 

of 

treatment. 


9 months 
3 months 
1 month 


3J months 
2 months 


3 months 
months 

1 month 

2 weeks 

21 months 

3 months 

2 months 


3 weeks 
2 months 

2 weeks 

3 months 

2 months 


3 j months 
I 7i months 
' IJ months 
2 months 


5 months 
months 
2 weeks 

1 month 


Results. 


Well. 

Improved. 

Well. 


Well. 

Improved. 

Under 

treatment 

now. 

Improved. 
Improved. 
Under 
, treatment. 
Under 
treatment. 
Improved. 
Well. 

Improved 

under 

treatment. 

Unim- 

proved. 

Well. 

Under 

treatment. 

Improved 

under 

treatment. 

Improved 

under 

treatment. 

Improved. 

Dead. 

Well. 

Improved 

under 

treatment. 

Well. 

Well. 

Unim- 

proved. 

Improved. 


months 'Well. 
1 j months i Well. 
I 5 months Well. 

1 ' 


8 



218 cashman: tubebculin therapy in surgical tuberculosis 

Ten of these were aged above and 18 below twenty years, 11 of 
the latter being under ten years and the remaining 7 between 
sixteen and twenty years. The dosage of tuberculin in this series 
varied from •jfg- mg. to | mg., showing a variation in suscepti- 
bility of a hundred fold. 

In the 10 cases above twenty years of age the dosage varied 
from yV lo 3^ iQg' ill 8 of them. In 1 case it was mg., 
and in the other it was f mg., which was the largest estimated 
dose in the series. This patient was aged twenty years. 

Of the cases below twenty years the dosage was mg. in 
3, To¥ mg- in 7, mg. in 3, ^ mg. in 4, and ^ mg. in 1. 

In a general wmy the dosage below tiventy years of age was 
near y-J-g- mg., wliile above twenty years of age it was near 
IT mg. This emphasizes the increased susceptibility to tuberculin 
of younger individuals. On the other hand the variations and 
exceptions, as in the case of the one patient above twenty years 
of age, for vdiom the dose ivas mg., sliows the value of a 
method wherebj^ the dosage is determined according to the indi- 
vidual susceptibilitj'- of the patient to tuberculin. 

The longest time during which any one patient was treated 
ivas nine months. 3 patients were treated for periods extending 
over seven months. In none of these was it necessary to change 
the dosage as originally determined by the skin test. There was 
noted from time to time a variation in the size of reaction produced 
at the site of injection, but this variation wms between 2 cm. and 

5 cm., which are the arbitrary’’ limits of the size of reaction that 
should be obtained at the place of injection. 

In 3 cases (10, 11, and 13) who stopped treatment before they 
were discharged, and who later returned for further treatment 
after intervals of nine to eleven months, it is interesting to note 
that the dosage remained the same. 

The method of determining the dose has been found reliable in 
all cases. Constitutional symptoms were obtained in 1 case (11), 
but through no fault of the method. In this case a reaction of 

6 mm. was obtained wdth ^ mg. of tuberculin on the skin. As 
there was not sufficient time to do another test before the next 
regular day for therapeutic injections, mg- was assurned^ to 
be the quantity that would produce a 4 mm. reaction. The injection 
of this quantity was followed by constitutional symptoms. Later, 

mg. was found to be the correct dose as determined by the 
sldn test, and was given without producing constitutional symptoms. 

Of the 28 cases, 11 are considered as well, 11 improved, 5 unim- 
proved, and 1 dead. As will be seen farther on, the 5_ unimproved 
cases were treated for too short a time to be considered in estimating 
the value of the method from the standpoint of end results. Ot 
the 11 cases discharged as well, 7 returned recently for examination 
and have remained well as follows: 



cashman: tuberculin therapy in surgical tuberculosis 219 

Case 1, twelve months after discharge. . 

Case 3, nineteen months after discharge. 

Case 4, twenty months after discharge. 

Case 5, sixteen months after discharge. 

Case 7, eight months after discharge. 

Case 16, three and a half months after discharge. 

Case 21, one and a half months after discharge. 

The remaning 4 were discharged as well, and have not been 
heard from since then. 

One of the chief difficulties experienced has been to get the 
patients to return for treatment after the visible lesions have 
healed. Cases with a sinus, as in cervical adenitis, were treated 
until the sinus healed, when frequently the patient would fail to 
return for further treatment, although other enlarged glands 
might be present. These cases have been designated as improved. 

Of the 11 cases improved, 2 (9 and 19) were cases of cervical 
adenitis, with sinuses, who, after the sinuses were healed, failed 
to return for treatment, and have not been heard from since. 
Tv^o cases (10 and 13) of cervical adenitis who discontinued the 
treatment after the sinuses were closed, returned later with recur- 
rence, and are at present under treatment. One case (20), with 
enlarged glands of neck without sinus, failed to return after the 
tenderness had disappeared. One case (23) had involvement of 
the axillary glands', vuth sinus. The sinus is now healed and the 
patient is still under treatment. Case 25, with tuberculosis of 
the hip, is apparently well and is still under treatment. Tour 
cases (2, 11, 14, and 18) have discharging sinuses which were 
definitely improved, but for various reasons these patients did not 
continue treatment. Two of them have not been heard from, and 
another (11) returned later and is at present under treatment. 
The other was almost healed when he left, and has written recently 
that the sinuses are healed. 

Of the cases marked as unimproved, 1 (25) received one injection, 
and 1 (22) received two injections and did not return for further 
treatment. 2 (27 and 28) have received one injection and 1 (26) 
received two injections, and are still under treatment. These 
cases are reported not for the final results, but because the dosage 
was determined by the method described above. 

The 1 case (6) with Pott’s disease wliich died, showed marked 
improvement symptomatically and in his general condition for 
two months, when he suddenly developed paraplegia and died 
eight months later. ^ With this one exception all cases treated 
have been cured or improved, as the cases marked unimproved 
were treated for too short a time to be considered in the end results. 

Many of the cases with sinuses which previously had been treated 
for months without improvement showed rapid improvement after 
the tuberculin injections were begun. This happened frequently 



220 pepper: influence of foreign bodies in gall-bladder 

enough to be more than a coincidence, and we believe, from our 
experience with this series of cases that tuberculin in doses deter- 
mined by this method is a valuable aid in the treatment of surgical 
tuberculosis. 

Conclusions. — 1. The variation in susceptibility of different 
individuals to the action of tuberculin is marked. 

2. The correct therapeutic dose of tuberculin for any individual 
can be determined accurately b}’’ the cutaneous reaction. 

3. Tuberculin therapy by this method is a valuable aid in the 
treatment of surgical tuberculosis. 

The writer desires to express his gratitude to Drs. R. T. Miller, 
Jr,, and R. R, Huggins, in whose services these cases were treated, 
for the privilege of reporting the same, and to Drs. White and Van 
Norman, of the Tuberculosis League of Pittsburg, for their valuable 
suggestions and aid. 

Note. — Since this paper was written the dose has been deter- 
mined by the above method and given without producing constitu- 
tional symptoms in two cases, viz., tuberculosis of the cervical 
glands and tuberculosis of the hip, making a total of 30 cases. 


THE INFLUENCE ON GASTRIC SECRETION OF ASEPTIC 
FOREIGN BODIES IN THE GALL-BLADDER. 

By 0. H. Perry Pepper, M.D., 

ASSOCIATE IN MEDICINE AND EESEAllCn MEDICINE IN THE DNIVEDSITY OF PENNSYLVANIA, 

PHILADELPHIA. 


(From the William Pepper Laboratory of Clinical Medicine.) 

These experiments ivere undertaken in the hope of finding some 
explanation for the gastric hyperacidity so frequently found clin- 
ically in association with cholelithiasis. As originally planned they 
formed part of an extensive series dealing with this subject, but 
before the work was completed, Lichty’s^ work on the same sub- 
ject and covering the same ground appeared, thus rendermg 
unnecessary their further prosecution. It seems worth while, 
however, to report the results obtained in the first simple phase 
of the investigation, partly because they are not in general in 
accord with those of Lichty and partly because they control possible 
sources of error in his work. These are the use of the stomach- 
tube in feeding the animals, the administration of food at irregular 
intervals, and the brief postoperative period of observation. 

1 The Relation of Disease of the Gall-bladder and Biliarj’ Ducts to the Gastric Functions, 
Amer. Jodr. Med. Sci., January, 1911. vol. cxU, No. 1. 



pepper: influence of foreign bodies in gall-bladder 221 

Lichty’s conclusions are briefly as follow: (1) That a lesion 
of the gall-bladder and ducts may disturb the gastric function. 
(2) This disturbance most frequently consists of a hypersecretion 
of gastric juice and a diminution of gastric motility. (3) So-called 
hjqierchlorhydria, with its accompan 3 dng symptoms, should be 
looked upon as an evidence of some definite pathological lesion 
somewhere in the gastro-intestinal tract or its appendages. 

Methods. The essential feature of the experiment was to place 
in the gall-bladder with as little trauma as possible a more or less 
smooth sterile object, too large to enter the ducts, and after appro- 
priate intervals to stud}'- the gastric secretion. The details follow: 

In the preliminary control period a series of dogs under similar 
conditions of environment were fed daily, after fasting at least 
twelve hours, a uniform test meal consisting of one dog biscuit 
and 50 c.c. of water. The gastric contents were removed forty 
minutes later and examined by the usual methods of the clinical 
laboratory. A sufficient number of test meals were given to secure 
a reliable average figure for each dog individually. Then under 
complete ether anesthesia the gall-bladder was opened, a sterile 
round pebble introduced, and the gall-bladder carefully closed again. 
A month was allowed to elapse in order to exclude immediate post- 
operative effects, and at the end of that time the gastric contents 
were studied, at intervals, for six weeks to eight months, and in 
one dog as long as eleven months, under the same conditions as 
before operation. The periods of observation were ten days in 
length, with daily examination. A control animal was at hand 
and was similarly studied from time to time. After the last period 
the dogs were chloroformed and the gall-bladder, stomach, and 
pancreas examined. 

This technique it was found could be very easily carried out. 
Dog biscuit was chosen because after they were accustomed to 
it the majority of the dogs would eat it readily, though, as a rule, 
a preliminary fasting of twenty-four hours was necessary before 
they could be induced to take the first meal. The dogs preferred 
the dry ground-up biscuits, which they devoured first, drinking the 
water afterward. Occasionally difficulty was experienced in per- 
suading a dog to take this meal, but as the method seemed in every 
way preferable to that of Lichty, that is, introducing the meal 
through a stomach-tube, it was adhered to in all instances. 
The dogs were kept quietly in their cages after the test meal for 
forty minutes and the contents then removed by stomach-tube. 
The passage of a stomach-tube in a dog is very simple if the animal 
IS properly gagged the first few times, after which with most dogs 
it can be performed without a gag by merely placing two fingers 
between the teeth alongside the tube. No effort was made to 
completely empt}' the stomach by lavage, as this was found to 
be very difficult if not impossible. In all about 300 test meals 



222 pepper: influence of foreign bodies in galu-bl.ujder 

were removed and examined. The first hundred gastric contents 
obtained were examined in full, but subsequently only the free 
hydrochloric acid and the total acidity were estimated. 

Five dogs were used, one of which was kept as control. The 
other four returned after operation to apparently perfect health 
and were studied for varying periods, one for only six weeks, two 
for eight months, and one for eleven months. At the autopsy on 
each of these four the foreign body was found in a gall-bladder, 
which was much shrunken and had greatly thickened walls, but 
showed no evidence of infection. Microscopic sections of the gall- 
bladder, stomach, and pancreas showed no significant changes. 

Result.?. The gastric analyses showed no changes as the result 
of the experimental procedure. (See Table.) In two animals 
the average acidity after operation was higher than before, while 
in the other two the reverse was true. In all the animals, both 
before and after operation, the averages for free hydrochloric acid 
lay between the figures 16 and 24.6. The figures obtained with 
Dog I wdll serve as an example. Before operation 20 satisfactory 
gastric contents were recovered, with an average figure for free 
hj^drochloric acid of 22.9. Five weeks after operation a series of 
nine meals gave an average of 20.1, three months after operation 
a series of ten meals gave 18.6, while eleven months after opera- 
tion ten meals gave 21.9. The general postoperative average was 
19.8. The difference between this and 22.9 is obviously too slight 
to be significant. 


Dog I V VIII X XII (controI)2 

Average before operation . . . 22.9 16 23 24.0 18.1 

Average after operation . . . 19.8 21.3 19.2 15 24.1 

The motility of the stomach did not seem in any instance to 
have been influenced by the experiment, although Lichty found 
retention in some of his cases. 

I wish to express my thanks to Dr. Floyd E. ICeene for his . 
performance of the operations. 

Conclusion. 1. For the study of gastric secretion in dogs 
repeated test meals (eight to ten must be given). 

2. The test meal can be fed by mouth, which is preferable to 

administering it by tube. _ „ , i i j f 

3. The introduction of a sterile pebble into the gall-bladder oi 
the dog caused no change in the gastric secretion or digestion or 
in the morphology of the stomach or pancreas within a period 
of eleven months after its introduction. 


‘ Not operated on, but studied at corresponding times. 



KAHN: CONGENITAL 


BILATERAL FISTHLiE OP THE LOWER LIP 223 


CONGENITAL BILATERAL FISTULffl OF THE LOWER LIP. 

By L. Miller Kahn, M.D., 

ADJUNCT attending SURGEON, LEBANON HOSPITAL, NEW YORK. 

Congenital bilateral fistulas of the lower lip occur so^ infrequently 
and the causative factors in their production are so slightly under- 
stood that the report of a case and a review of the literature seem 
to be timely. 

After a careful search I was able to find but 22 reported cases, 
my own making 23 in all. 

0. H., male, aged three years. There is no member of the farnily 
who, so far as is known, has had any facial or other congenital 
deformity. The mother and father are normal individuals. No 
history of syphilis. The child is well. 

The photograph shows the fistulse as they open on either side 
of the middle line of the lip. There is a slight puckering of the 
mucosa, forming an oval in the centre, of which there is a small 
opening which will ]ust admit a probe point. The tract then runs 
downward and inward toward the median line, and the fistulas 
end in blind pockets just under the mucous membrane of the lip 
on the inner surface. The entire length of each fistula is about 
1.5 cm. These fistul© do not communicate, but at the terminal 
portion, which lies near the inner side of the lip, they are separated 
by a thin partition, probably of fibrous tissue. The openings of 
the fistulas are filled with a glairy secretion, which is transparent, 
and when this is wiped away returns in a few minutes. As it does 
not give the child much trouble, excision at this time is not 
permitted. 

The first observation of this condition was made in France by 
Demarquay^ in 1845. Demarquay saw a mother and child, and 
in each there was a similar condition — ^harelip, cleft palate, and 
bilateral fistula in the lower lip. No microscopic examination of 
the tissue taken from the fistulous tract was made, and he con- 
cluded that the condition in the lower lip w^as due to abnormally 
developed, hypertrophic follicles. 

• In 1858 Beraud^ described similar deformities in a case and in 
1860 Murray^ saw four cases in one family and found many other 
congenital deformities in other members of the same family. 
Murray thought the condition due to some intra-uterine disease 
of the mucous glands in the lip. 

Richet^ saw a grandmother and mother and child in w'^hich the 
condition of bilateral fistul® of the lower lip was present. Two 

1 Gazette m^d., 1845, pp. 52 and 1868. 

’ Gaz. des H6p., 1861, No. 73, p. 291. 

* British and Foreign Med. and Surg. Rev., October, 1860, 

* Gaz. des H6p., 1861, p. 174. 



224 KAHN: congenital bilateral fistuhe op the lower lip 

of these cases had been published earlier by Demarquay. Richet 
also saw several cases in a family in which there were other con- 
genital anomalies in other members of the family. Those who 
had fistulie of the lower lip had no harelip. 

Rose, in Zurich,® reported a case with division of the lower lip 
and prolongation of the divided sides. In the ends of the two 
prolonged halves of the lower lip were fistulous openings, one in 
each side. Each opening led into a tract about 2 cm. in depth, 
which secreted a clear fluid. Ahlfield credits Rose with three 
other cases. 

Madelung® saw a child, aged one month old, with harelip and cleft 
palate, and while the contour of the lower lip was normal there 
were present two tiny teats sj^mmetrically placed one on either 
side of the middle line of the lip and puckering the mucous 
membrane of the lip. On squeezing the lip a clear fluid could be 
expressed. It was not possible to prove the existence of fistulas 
with the sound, but excised portions showed, on microscopic 
examination, the presence of canals. These canals were lined with 
mucous membrane covered with epithelium and large, pointed 
papillae, which differentiated it from the normal mucosa of the 
lip. On sagittal section muscle fiber was found on the side toward 
the inner aspect of the lip. These fibers ran parallel to the fibers 
of the orbicularis oris. On the side of the canal toward the skin 
no corresponding muscle fibers were found. There was therefore 
no structure resembling a sphincter. 

Zeller,^ in 1888, saw a case in von Bergmann’s clinic, and collected 
all previously reported cases. There were 18 cases in all, including 
his own, 12 of which were accompanied by double harelip, 2 with 
single harelip, in 2 cases it was not stated, and in 2 cases the fistulas 
of the lower lip were unaccompanied by any other congenital 
deformity. After exhaustive study of the embryologie and mor- 
phologic data he concludes that congenital fistulae of the lower 
lip are the remains of the fetal furrows in the inferior maxilla, due 
to amniotic adhesions. 

Zeller’s reasoning is as follows; “It is known from the work 
of Iflotz that amniotic filaments Avhich have partly lost their 
attachment to the amnion remain at the connecting point with 
the fetal skin, and consisting of normal skin, sometimes reacli 
a length of 2 cm. An amniotic filament (/adm) that has prema- 
turely lost its connection with the amnion either dies or perhaps 
in part is nourished by the fetus and takes on fetal characteristics 
— that is, is changed into tissue identical with that which arises 
from the same primary layers. 


5 Monats. f. Geburtskunde, Band xxxii, 1868. 

6 Archiv f. kUn. Chir., 1888. . n r tboi 

’’ Ueber nngeborene Unterlippenfisteln und Wurzchen. Dissertation, Berlin, 



KAllN: congenital SILATERAL EISTUL^E OF THE LOWER LIP 226 

The papillse and fistulse of the lower lip are probably due to 
such amniotic rests acting as adherent filaments in the fetal furrow 
of the lower lip.” 

Stieda* after reviewing the probable causes and the embryologic 
questions involved arrives at the following: (1) Fistulse of the 
lower lip are not due to arrested fetal development. (2) Fistulse 
of the lower lip arise from excessive growth through closure on 
both sides of the embryonal furrow of the lower lip— that is, through 
transformation of the lateral furrows into one canal, (3) The embry- 
onal side furrows of the lower lip disappear usually during fetal 
life; in exceptional cases they persist throughout life. Stieda's 
case presented the typical picture in the lower lip, and also had 
harelip and cleft palate. 



Case of congcmtal bilateral fistulas of the lower lip. 


Goldflam,® in 1907, reported a case with no involvement of the 
upper lip, and agreed with Stieda’s conclusions. 

The only cases reported from America were published by de 
Nancrede^® in 1912. 

De Nancrede found two cases in one family, the children present- 
ing typical bilateral fistulee of the lower lip, and offers the follow- 
ing explanation of the condition, by Dr. G. C. Huber, of the Uni- 
versity of Michigan: “On either side the well-known median 
notch seen to persist some time during intra-uterine life after fusion 
of the two halves of the lower lip has been completed, it is not 
unusual to detect a slight secondary notching on each side. This 
becomes deeper, its deepest portion becoming gradually buried 


* Archiv f. klin. Chit., Band Ixxis, No. 2. 

* Munch, med. Woch., January S, 1907. 

"> Annals of Surgciy, September 1912, p. 400. 


PILCHER: THE ETIOLOGY OE PERNICIOUS AIUSMIA 

until a short tubular tract lined with mucosa is formed. Why 
this fixation of the deepest portions should occur, permitting the 
normal depth of the lower lip to develop, is of course conjectural.” 

The treatment of the fistulse, when treatment is indicated, is 
by excision. 


A CONTRIBUTION TO THE ETIOLOGY OF PERNICIOUS 

ANEMIA.^ 

By James Taft Pilcher, M.D., 

BROOKLYN, NEW YORK. 


In 1860 Flint published his inferences regarding the atrophy of 
the stomach mucosa in cases of pernicious anemia. Ten years later 
Fenwick actually demonstrated the gastric lesion and worked out its 
pathology. Quinke, in 1876, was, however, the first, I believe, to 
consider the gastric changes as the causative factor of the anemia, 
while Martius, Lubarsch, and Koch considered the pathological 
findings in the stomach and intestines as secondary factors; 

We appreciate now, however, that some hemolytic agent is 
present in the blood, and various theories have been advanced as 
to its origin. Hunter, in 1890, seems to have been the first to 
recognize this, and believed that some toxin was produced in the 
stomach in certain cases which was responsible for the hemolysis. 
Much pathological research was done to isolate this ptomain, and in 
1898 Schauman, Faust, and Tallquist recovered a lipoid substance 
from the segments of the bothriocephalus, which when administered 
to animals reproduced a blood picture resembling closely that of 
pernicious anemia. This they considered either a sodium or 
cholesterin combination vutli oleic acid. 

Ten years later, in 1909, Berger and Tsuchyia extracted a lipoid 
substance from the gastric and intestinal mucosa of patients who 
had died from pericious anemia, which showed hemolytic pro- 
perties ten times stronger than extracts obtained in other condi- 
tions. They further reproduced, by animal injection of this 
extract, an anemia of the pernicious type. 

Faber, who has probably made the most searching studies of 
the gastro-intestinal pathology in this disease, states that the 
changes noted in most intestines are postmortem, and vill not 
be foxmd present if the part is preserved immediately after death, 
but that the atrophy in the stomach is constant, and that in the 
stomach the etiologic factor must be sought for. 

Herzberg, in a careful pathological study of 9 cases, concurs 

I Read at the Fifteenth Annual Meeting of the American Gastro-enterological Association, 
and before the Brooklyn Society of Internal Medicine, November 22, 1912. 



Pilcher: the etiology op pernicious anemia 


227 


with Faber and believes that the gastric and blood phenomena in 
pernicious anemia arise from the same cause. 

It is with the hope that some light may be thrown on this etiologic 
factor that the following observations are presented. 

In the analysis of 433 cases of abdominal complaint presenting 
the symptoms of aclilorhydria haemorrhagica gastrica, most of 
wliich were observed at the Mayo clinic, there occurred during 
1909, 1910, 1911, 34 cases of pernicious anemia. All cases of per- 
nicious anemia presented the findings of an achlorhydria haemor- 
rhagica gastrica. Two cases of pericious anemia examined one year 
before the blood dyscrasia evidenced itself showed lack of free 
hydrochloric acid and the presence of occult blood in the stomach 
extract. Many of them gave long histories of chronic digestive 
disturbances before there was any blood change, but no stomach 
analysis is recorded. Several developed marked paresthesia of 
the extremities when their blood showed as yet only a slight 
secondary anemia, with no evidence of a pernicious character. 

Of the 433 cases of achlorhydria examined, 149 were operated on 
as they presented definite intra-abdominal disease. Gross patho- 
logical findings in these showed involvement of the appendix in 52 
cases; the gall-bladder in 57 cases; the gall-bladder and pancreas 
in 21 cases, and the stomach in 19 cases. There were 19 cases 
in which the gall-bladder was diseased concomitantly ivith the 
appendix. 

The anamnesis in 156 of the remaining cases developed the fact 
that the onset of gastric symptoms seemed to bear an immediate 
and direct relation to various diseases and conditions, among which 
the incidence of infectious diseases in 38 cases, circulatorj'^ disturb- 
ances in 12, postoperative development in 14, and derangement 
of the ductless glands in 20 instances, deserve mention. 

Appreciating generally the extraordinarj'^ degree of gastric dis- 
turbance which irritation in distant organs can produce, it may 
be considered even more than a presumptive conclusion that 
reflex nervous phenomena are responsible primarily for the inhibi- 
tion of the production of hydrochloric acid in these cases. 

The bacterial flora present in cases of achlorhydria haemorrhagica, 
achylia gastrica, and pernicious anemia are identical. Streptococci, 
colon, diplococci, lactic acid, staphylococci, proteus, and leptothrix 
are present in great numbers. Frequently all varieties may be 
seen in the same field so great is their profusion. In several instances 
the cells of the mucosa itself had taken on phagocjdic properties. 
A chemical analysis can be foretold almost vdthout exception from 
this picture of the bacterial flora under the microscope, and ample 
control of these observations by repeated examination of the flora 
existing in cases of h^qjeracidity, normal and hj'poacidity, and in 
malignant and non-malignant stenoses seem to justify the folloiving 
conclusions: 



228 


PILCHER: THE ETIOLOGY OF PERNICIOUS ANEMIA 


That in the stomachs of patients presenting the symptoms of 
lack of free hydrochloric acid there is present a very large number 
of bacteria. Varieties ordinarily pathogenic are almost universally 
found either alone or in combination; that their presence is 
dependent upon the lowered acidity of the gastric Juice, that 
they are actively growing bacteria, evidenced by their profusion, 
morphological characteristics, and staining properties; that the 
streptococci are probably the most important factors, since 
they are found in large numbers in those cases where pus was 
noted. 

My interest in this question of the bacterial content in the 
stomach in cases of achlorhydria and pernicious anemia was lately 
stimulated by an article by McCaskey, who was able to obtain 
from the blood cultures, streptococci in each of the cases of per- 
nicious anemia examined by him, in two of wluch administration 
of an autogenous vaccine appeared to be instrumental in over- 
coming streptococeemia, and further remarks that all the cases 
in which fever was present in whom blood cultures were made, 
showed the presence of streptococci. This was significant when 
one appreciates that fever occurs in approximately 80 per cent, of 
cases of pericious anemia. In further analyzing this phenomenon 
we find it continuing at times for weeks, or recurring periodical!}^, 
but absent during the remissions which so frequently occur, and 
when, as Moffitt has noted, in certain cases of high temperature, 
profound exhaustion, nervous phenomena, and an enlarged spleen 
are noted they speak strongly in favor of an infective agency. 

Fejes has demonstrated that anemia may be produced experi- 
mentally by bacterial hemolysins. Toxins produced by certain 
strains of streptococci have been shovm to be distinctly hemolytic. 

When one reflects upon the various means employed to treat 
pernicious anemia, the fact must seem apparent that possibly 
unconsciously they have all been worldng empirically to effect 
the same result, namely, the cleansing of the gastro-intestinal 
tract by the administration of medicines which we have lately 
learned to be germicidal in their action. Thus intestinal lavage, 
appendicostomy with colonic irrigation, administration by mouth of 
intestinal antiseptics, lavage of the stomach, thorough evacuation 
of the bowels, arsenic in its various forms, as Fowler’s solution, 
and intravenous injections of salvarsan, autogenous vaccines, and 
finally hydrochloric acid. 

I vdsh then to present for consideration these facts, namely: 

1. Achlorhydria is merely a sjonptom denoting a marked degree 
of chronic gastritis. 

2. It is usually evoked through extragastric irritative factors 
which are in many instances capable of correction. 

3. There are, without exception, present in such^ stomachs great 
numbers of bacteria ordinarily considered pathogenic, among which 
streptococci are especially to be noted. 



PILCHER: THE ETIOLOGY OF PERNICIOUS ANEMIA 


229 


4. Practically all recorded cases of authenticated pernicious 
anemia present the symptom of achlorhydria, and in my own 
series of thirty-four cases the presence of occult blood in the 
stomach extract. 

5. Thirty-four instances of pernicious anemia were noted ^ in 
patients presenting the symptom of achlorhydria hsemorrhagica 
gastrica. 

6. In a few of these cases the lack of hydrochloric acid and the 
presence of occult blood were known to be present at least one 
year before any blood changes were to be noted. In others the 
phenomena of paresthesia were evidenced some time previous to 
blood impairment, and many had suffered for years from chronic 
gastro-intestinal complaints. 

7. Eighty per cent, of cases of pernicious anemia have increased 
temperature some time during the course of the disease. 

8. Pure cultures of streptococci have been found by competent 
observers in the blood of patients with pernicious anemia who 
were running a fever. 

9. Bacterial hemolysins are known to produce anemia resembl- 
ing the pernicious tj^e, as are other toxic substances, among 
which may be classed the lipoid group. 

10. Efforts directed to the control of bacterial growth in the 
body and particularly in the gastro-intestinal tract have caused 
complete remissions in this disease in some instanees. 

11. The phenomena of occurrence, remission, and re-occurrence 
of the blood picture characteristic of pernicious anemia may be 
explained by our present knowledge of the action of toxins from 
whatever source, impairing the formation of antibodies until a 
bacteremia is produced which may be clinically recognized. 

12. The toxins we have present being eliminated by the profuse 
flora in the gastro-intestinal tract, the impairment of bodily 
resistance is accomplished through their absorption and the dis- 
turbance of digestion in cases of achlorhydria. 

13. Finally, reactive and combative ability of patients suffering 
with achlorhydria varies in different patients, and on this ground 
alone might be explained the relatively rare occurrence of pernicious 
anemia, although the occurrence of achlorhydria is fairly common. 

Thus the development of pericious anemia would seem to be 
dependent upon a personal idiosyncrasy of certain indi\dduals, 
in fact we must revert for the real etiologic factor of its inception 
to an embryonic tendency, the presence of which we are not as 
yet able to determine until it has been stimulated into an active 
destructive agent of the blood by the toxdns absorbed from the 
profuse bacterial flora present in the stomach. 



230 


NILES : THE ROLE OF HYDROTHERAPY IN PELLAGRA 


THE ROLE OF HYDROTHERAPY IN THE TREATMENT OP 

PELLAGRA. 

By George M. Niles, M.D., 

PROFESSOR OF GASTRO-ENTEROLOGY AND THERAPEDTICS, ATLANTA SCHOOL OF MEDICINE, 

ATIANTa, GA. 


Like the task of firemen, who are compelled to fight the evident 
and rapid combustion of some huge and many-sided structure — not 
halting their efforts in order to discover its origin, nor abating 
their struggles to quench the flames, while others of their number 
are seeking the hidden source — ^so this problem of pellagra has 
been abruptly thrust upon the medical profession of the United 
States. 

It has assumed menacing proportions with all the suddenness 
of a forest fire, and, while many earnest investigators have been 
delving at the etiologic questions involved, the actual, therapy 
would not wait upon their dicoveries or conclusions. Pellagra as 
a pathological entity has been placed before us, and of necessity we 
have had to administer some form of treatment, whether rational 
or otherwise. 

The writer admits, with sorrow, that the etiology of pellagra is 
still in doubt. The zeists, or those who believe with the late 
Lombroso, that “In pellagra we are dealing with an intoxication 
produced by poisons developed in spoiled corn through the action 
of certain microorganisms in themselves harmless to man,’" are 
still in the majority. The antizeists, however, number among 
their ranks some doughty spirits, and we have the satisfaction 
of knowing that this important question will never be settled until 
it is settled correctly and beyond peradventure. In the mean- 
while various procedures have been advocated, some apparenti}'- 
possessing merit; others most bizarre and fantastic. 

It may be said that, with the exception of a few pessimistic 
individuals, who have found no distinctive pathologic lesions other 
than those coincident with senility, and therefore have consigned 
pellagra to the realm of incurable maladies, the larger number of 
those actually called upon to treat this disease have approached 
the difficult and obscure problems with a courageous _ feeling. 
They have evolved a fairly complete line of therapy, meeting "with 
a large measure of success most of the indications, and their 
good results are not necessarily dimmed by the fact that some 
of their methods are empirical. 

The medicinal, dietetic, hygienic, and even psychic treatment 
has been covered in recent literature, easily available to those 
interested. In hydrotherapy, though, we have an auxiliary whose 
helpful potentialities have not been sufficiently appreciated, and 



NILES ; THE HOLE OP HYBEOTHERAPY IN PELLAGRA 


whose aid may be invoked with confidence in some of the most 

distressing phases of pellagra. ^ i • 

No claim for originality as to methods is made^ but in their 
special application to this protean disease the writer trusts that 
some new and worthy suggestions may be^ adduced. 

Let it be briefly stated that in pellagra we have a fourfold syn- 
drome — gastro-intestinal, dermic, nervous, and psychic— one or 
more units of which may predominate. Some of the typical cases 
may show at once all four units of the symptom-complex, but, as 
a general rule, one to three are manifested, while the others are 
partly or wholly in abeyance. 

It is hard to imagine a more melancholy spectacle than a con- 
firmed pellagrin, with his anorexia and indigestion and diarrhea; 
his parched and discolored hands, and perhaps face and feet; 
his burning tongue and extremities, coupled with shooting pains 
in different parts of the body; and often, overshadowing all, his 
changed mentality, varying in temperamental shade from indefinite 
blues to the blackness of melancholy and dementia. 

Granted that all other possible therapeutic means are being 
assiduously employed, hydrotherapy may be advantageously 
used, first for gastro-intestinal symptoms. For the frequent and 
sometimes constant nausea the drinking of from two ot six glasses 
of tepid water once or twice daily, so that by its emesis the stomach 
may be washed, will prove beneficial. Where it can be expertly 
performed, lavage once daily is better; but unless the medical 
attendant is an adept at introducing the stomach tube, lavage is 
best not attempted. In addition a cold water bag over the epigas- 
trium placed there a half-hour before meals, and kept on fifteen 
to thirty minutes, plus drinking a half glass of iced water, exerts 
both a sedative and stomachic effect. 

The frequent diarrhea may be greatly alleviated by hot colon 
irrigations, followed by cold sitz baths of five to ten minutes 
duration. This double procedure may be repeated two to four 
times daily when the patient is not too weak. 

Another valuable method consists in the use of cold abdominal 
compresses, sometimes called ‘'Neptune’s girdle,” in which the 
abdomen is encircled by a thick towel of liberal proportions, 
saturated with cold water. This may be removed and resaturated 
every one or two hours. Copious water-drinking is generally 
advisable, tending by its volume to keep the kidneys “flushed,” 
and, by its solvent power, diluting and washing out many of the 
toxins. The diarrhea, being of central origin, and mainly compensa- 
tory in character, is rarely increased by an abundance of water 
in the body. Occasionally the writer has seen the bowels apparently 
regulated by. this means after they failed to respond to astringent 
or dietetic endeavors. 



NILES; THE ROLE OF HYDROTHERAPY IN PELLAGRA 


For the occasional constipation, warm enemas, high if necessary, 
are always in order, and always efficacious. ^ 

To increase skin elimination there can be used the so-called 
“long bath” or various hot packs. A caution in regard to the use 
of the electric-light chamber is timely, for this is contraindicated 
in pellagra on account of the danger of kindling or increasing 
dermal symptoms. The skin of all pellagrins is peculiarly sus- 
ceptible to the influence of any strong light, and the attending 
physician will avoid some troublesome complications by keeping 
this fact in mind. 

For the dermal manifestations, expressed by erythema and 
sundry grades of dermatitis, hydrotherapj’’ has but a limited field 
of usefulness. Apart from keeping clean the surface of the body, 
water has no specific effect; indeed, where the skin sj’^mptoms are 
markedlj'' eczematous it is well sometimes to omit bathing the- 
crusted surfaces for a brief season, using oily applications instead. 
In the occasional troublesome itching of the skin a cool or cold 
saline bath is often grateful. This may be made by the addition 
of chloride of sodium,- seven pounds; chloride of magnesium, 
one pound; sulphate of magnesium, half pound; water, .thirty 
gallons. 

In many of the neuroses we derive most comforting results from 
hydrotherapy. The burning hands and feet may be greatly 
soothed by either ice-cold compresses applied at frequent intervals, 
or baths in hot mustard water. In addition may be employed 
hot leg-and-arm-packs, and revulsive compresses to the spine. 
In the use of the last named the hot compresses should stay on 
from three to five minutes, while thirty seconds will be sufficient 
for the cold. Three treatments daily, of thirty minutes’ duration, 
are sufficient, and the relief obtained is often remarkable. These 
neuroses, being the painful expressions of lesions in the nerve 
centres, are most stubborn, sometimes remaining in evidence 
long after all other traces of pellagra have disappeared; and these 
special baths, packs, and revulsive compresses have proved helpful 
in a number of cases under the observation of the writer, where 
analgesics and anodjmes had failed to afford any lasting cessation. 

It is perhaps in those pellagrins where the psychic manifestations 
predominate that hydrotherapy holds the widest and most useful 
scope. For the mental disquietude with transient exliilaration, 
associated vdth insomnia, the neutral full bath at 94° to 96 , last- 
ing from one to two hours, morning and evening, exerts a soothing 
effect. This may be augmented by warm compresses to the back 
of the neck, kept on about fifteen minutes, and applied three times 
daily. Should the patient seem somewhat autotoxic a free perspi- 
ration can well be induced at the end of these neutral baths by 
the use of hot packs, followed by suitable and brief cold applications. 

He should also drink water freely. In this connection a daily 



ROBERTS: THE ANALOGIES OF PELLAGRA AND THE MOSQUITO 233 

hot enema is often comforting even if not specially indicated by 
any abnormal bowel condition. _ ' 

For mental depression and melancholia the cold percussion spinal 
douche bath exerts a decidedly good effect. If the patient is 
robust phj'^sically this douche bath maj'' begin as low as 45°, but 
65° to 70° is usually better. Should this not be agreeable, spinal 
sponging, alternating with hot and cold water, affords a passable 
substitute. Pellagra, being in the main an afebrile disease, cold 
packs are seldom indicated, though in some “typhoid” cases, 
with muttering delirium, they hold a doubtful place. 

For the anemia and debility so often following in the wake of 
acute pellagra, cold measures, discreetly applied, yield not only a 
tonic effect but also an appreciable effect on the red blood count. 
This was proved by Prof. Winternitz as far back as 1893. 

Practically all of these hydriatic measures, with the possible 
exception of the alternating douche, can be carried out at the home, 
though naturally a well-equipped institution, with trained attend- 
ants, can apply them with greater ease and precision. 

The writer feels constrained to acknowledge valuable sugges- 
tions from Mr. W. W. Blackman, of Atlanta, whose wide experience 
in hydrotherapj^ and painstaking efforts have demonstrated the 
utility of hydrotherapy in many instances. 

Until a specific is found for this dread disease it is our duty 
to afford these forlorn sufferers every intelligent means of relief, 
and, from observation of over seventy-five pellagrins, with whom 
some form of hydrotherapy was employed, and in whom some meas- 
ure of relief was noted in every instance, the writer presents it 
as worthy the thoughtful consideration of those who are burdened 
with the weight of this difficult problem. 


THE ANALOGIES OF PELLAGRA AND THE MOSQUITO.^ 

By Stewart R. Roberts, S.M., M.D., 

PROFESSOn OF MEDICINE IN THE ATLANTA COLLEGE; PHYSICIAN TO THE 
■WESLEY MEMORIAL HOSPITAL, ATLANTA, GEORGIA. 

With the publication of Sambon’s Progress Report, in 1910, 
the investigation of pellagra really began. Before that time men 
studied a cereal, and thought they Avere studjdng a disease. Sam- 
bon s name will be associated with two great propositions concerning 
the nature and cause of pellagra: (1) The hypothesis that it is 

> Read before the Second Triennial Congress on Pellagra, Columbia, South Carolina. 



234 ROBERTS. THE ANALOGIES OP PELLAGRA AND THE MOSQUITO 

an infectious disease, and (2) tlie hypothesis that it is an insect- 
borne disease. 

To many students these hypotheses stand as facts, because 
supported by much evidence and therefore believed; to others 
they are only hypotheses, and therefore only theories, because un- 
proved. The third idea advanced by Sambon, namely, that the 
Simulium fly is the specific insect carrier, is open to far larger 
doubt than his first two propositions; and reasoning by analogy, 
and by the analogies of etiology, and by many notable comparisons, 
this fly is not nearly so apt to be the insect agent as is the mosquito. 

The following objections hold against the Simulium as the 
disease carrier: So far as is known, the bite of the Simulium is 
poisonous rather than infectious; bearing toxins rather than para- 
sites. The disease appears in America chiefly in those who are not 
field laborers, and who are little exposed to its bite. Pellagra 
occurs in sporadic cases in cities, among women who stay at home, 
and in asylums within doors, where the Simulium neither comes 
nor bites. It does not present the regularity of seasonal incidence, 
adults living through the winter, the repeated broods during spring, 
summer, and autumn, in enormous numbers as does the mosquito. 
It does not move in swarms far from its stream home, and, therefore, 
does not explain those cases arising at a distance from any running 
stream. It is more numerous in cold countries and on the coast 
of all continents, while pellagra avoids cold climates and seeks the 
interior rather than the coast. 

The insect which carries the pellagrous parasite must account for 
and explain certain ecological and geographical facts of the disease, 
such as: Its seasonal relations, its periodicity, its recurrences, and 
its chronicity; its endemic relations, its occurrence chiefly in rural 
environments, its absence from cities except in sporadic cases; 
its peculiar geographical distribution over the world, in Africa 
along the Nile, in southern Europe, southern North America, and 
the West Indies; its predominance among females and in those who 
work around the house,, as in women who wash clothes near the 
home; its attack on all ages and both sexes, infants, adults, and 
octogenarians; the spread of the disease in new areas, its epidemics, 
and their variations in severity; the severity of the disease in its 
first sweep of a new area, as in Roumania and America; and the 
increasing immunity to the disease in Spain and Italy, where it has • 
raged for two centuries; its association with mosquito-borne dis- 
eases; its association with streams, swamps, foothills, valleys, 
lowlands, and standing water in damp areas. 

The following analogies of etiology and comparisons with mos- 
quito-borne diseases show a relationsliip to a common insect host, 

the mosquito. . 

Pellagrins are insane, become inmates of asylums, and insane 
inmates conversely become pellagrous, as in the Alabama epidemic 



EGBERTS: THE ANALOGIES OF PELLAGRA AND THE MOSQUITO 235 

reported by Sesrcy, the Illinois asyluin cases reported by Zellar, 
the Jamacia cases reported by Williams, The two sexes are more 
equally affected in those who develop the disease within the asylums, 
and within doors both sexes are equally exposed to the infecting 
agent. The insect probably lives and bites in houses. 

In Italy, Roumania, and America pellagra predominates in 
females and in those individuals of both sexes that remain in and 
around the home during the day. They are more exposed than those 
away from home working in the fields or woods. 

The mosquito accounts for the fact that a woman in the family 
may become pellagrous, and other women in the same house develop 
the disease. They are together day and night equally exposed to 
the infecting agents. On account of this spread of the disease in 
one family, under one roof, chiefly among women and children, 
it has in certain endemic areas been considered contagious, as was 
yellow fever before the Stegomyia faseiata was discovered to be 
the agent in its distribution. 

For pellagra to appear in the United States, either the parasite 
or both parasite and insect host must have been lately introduced. 
For it to spread the parasite must be naturally fitted to the climate, 
seasons, and to insect and human hosts; the insect host must be 
adapted to climate, seasons, habitat, and environment. For such 
adaption to exist on the part of the insect it must have been in 
America many centuries and in enormous numbers. The parasite 
of pellagra has, therefore, probably been recently introduced, and 
its specific insect host is a natural, long time inliabitant, present 
in enormous numbers, as is the mosquito. For instance, Stegomyia 
faseiata was found in hlilledgeville, Georgia, in September, 1912, 
in a soft-drink stand, but the yellow fever agent was lacking, and 
there was no yellow fever in the city. 

Like malaria and filariasis, pellagra is chiefly rural. Rome es- 
capes malaria, and yet in the marshes without the city the disease 
rages. Bucharest, Milan, and Atlanta escape pellagra, but in the 
regions round about the disease persists. Even in large cities 
sporadic cases of malaria and pellagra develop,- they usually occur 
on the outskirts, where the drainage is poor and filth and sewerage 
abound. 

Pellagra has an unquestioned relation to streams, swamp areas, 
standing water, and places that breed the mosquito, as have malaria 
and yellow fever. This is true in Egypt along the Nile, in Greece, 
Roumania, Italy, Spain, and America. 

Hills tend to escape in areas visited by pellagra, malaria, yellow 
fever, and filariasis. 

In areas both malarial and pellagrous, rains and floods that 
increase malaria, also increase pellagra. With the proper drainage 
of such an area, both diseases decrease and later disappear, as 
illustrated by the Landes in southern France, 



236 ROBERTS: THE AN-ALOGIES OF PELLAGRA AKD THE AIOSQUITO 

Mosquito-borne diseases have a seasonal incidence. Yellow 
fever in spring, summer, and autumn; malaria in spring, summer, 
and autumn; pellagra in spring, summer, and autumn. Yellow 
fever depends in its endemic areas upon the time of the appearance 
of the Stegomyia; malaria upon the Anopheles; pellagra upon its 
specific mosquito host. The first attack of pellagra may develop 
any time froni early spring to fall, for the reason that several broods 
of the mosquito host appear during this period. 

hlalaria, yellon^ fe^^er, filariasis, and pellagra tend to appear 
and become epidemic with spring and early summer. Within the 
bounds of latitude the outbreak of these diseases is later in the 
spring and summer as one goes farther North, and earlier as one 
goes farther South. The annual pellagrous attack tends to be earlier 
the second summer, and the earlier the spring season the sooner 
the attack; this is also true of malaria. 

Pellagra appears and persists in cotton-mill communities in the 
South, and is absent from cotton-mill and factory communities 
in the Eastern States. There is probably an infected mosquito 
in the South which is absent from the East. The usual factory 
reservoir, the puddles of water, the surface closets, the washtubs 
in every back yard, the rain-water barrels, the mosquito-breeding 
areas, the women at home, are all consistent with the mosquito 
as a reasonable hypothesis. 

Malaria, yellow fever, filariasis, and pellagra all tend to cease 
spreading, the cases improve, and the disease dies away wdth the 
coming frost, cold, and winter. All these diseases avoid the winter be- 
cause of the influence of the cold season upon both palrasite and insect. 

Pellagra, like malaria, yellow fever, filariasis, and dengue fever, 
has its epidemics, its years of severity and mildness, its ebb and its 
flow of prevalence and of intensity. 

Pellagra, malaria, yellow* fever, and filariasis are all endemic in 
restricted areas for a century, and epidemic at different times. 
These endemic areas are mosquito breeding-areas, and in times of 
epidemic mosquitoes are present in great numbers. 

Pellagra and malaria have latent periods and periods of activity, 
due to the change in the seasons, the fixed life-period of the parasite, 
and its alternating periods of activity and rest; and to changes 
in climate, altitude, and vitality. Spring may usher in an attack 
of malaria or of pellagra. A surgical operation or a confinement 
may float a latent pellagra or a latent malaria. 

Pellagra, malaria, yellow* fever, and filariasis are non-contagious 
and non-inheritable. 

The incubation period in malaria is ten days to three weete; 
in yellow^ fever thirty-six hours to fourteen days; in pellagra prob- 
ably tw*o to three w’-eeks, certainly less than four weeks. Sambon 
recently found pellagra in an infant one month old. This fact 
signifies kinship of insect carriers. 



ROBERTS: THE ANALOGIES OF PELLAGRA AND THE MOSQUITO 237 

The parasites that cause malaria, yellow fever, _ and filariasis 
are more restricted in their endemic areas and in their geographical 
distribution than their insect hosts. Anopheles has a wider dis- 
tribution than the Plasmodium malariae; Culex fatigans than the 
Filaria bancrofti, and Stegom 5 da fasciata than the yellow fever 
agent. The same relational distribution of parasite and mosquito 
probably applies to pellagra. 

Pellagra is absent from Ireland, Avhere Simulium flies occur in 
abundance, but mosquitoes are relatively scarce. Malaria, yellow 
fever, filariasis, and dengue fever are also absent from Ireland. 
Furthermore, the poorest Irish peasants, whose poverty is famed 
and world-wide, eat Irish potates and ‘'yellow meal,” the latter 
being imported as shelled corn, from America, Africa, and Russia 
through the Baltic Sea, and yet there is no pellagra in Ireland. 

Scotland,^ practically all of England, and Australia are free 
from pellagra, malaria, filariasis, and yellow fever. Canada is 
likewise free from all these diseases, except a small area on the shore 
of Lake Ontario, where a few malarial cases occur. Except for 
Illinois, Avhere five hundred cases of pellagra have occurred, and 
a few sporadic cases in the northern and western United States, 
pellagra, malaria, and yellow fever all tend to remain in tlie southern 
United States and farther southward. A further significant fact 
is that the Illinois cases are chiefly asylum cases. 

Practically all pellagrous areas are also malarial areas, except 
in the small island of Barbadoes in the AVest Indies, where pellagra, 
yellow fever, and filariasis occur, but no malaria. On the nearby 
island of Jamaica, however, all four diseases exist, pellagra, malaria, 
yellow fever, and filariasis. Pellagra is to Italy and Roumania 
what yellow fever is to the West Indies, and what malaria is to 
Greece and to the foothills of the Himalayas in India. 

Pellagra extends from 8° to 45° north latitude. Forty degrees 
north latitude cuts the pellagrous area of Europe into northern 
and southern halves, and 45° mark its northern limit; 30° north 
latitude cuts the pellagrous area of Africa; and the same parallel 
cuts the North American area, noth 8° in Panama as the southern 
and 45° in New York as the northern limit even in sporadic cases. 
The distribution of pellagra in three continents is marked by an 
average latitude of 30° to 45°, and 90 per cent, of the pellagra 
cases in the world occur in this belt of 15°, or a distance of 1000 
miles from north to south. In this belt occur also malaria, yellow 
fever, filariasis, dengue fever — all the mosquito-borne diseases. 
Furtherinore, while Anopheles occurs in this area, the northern 
distribution of pellagra generally marks the northern limit of 
Stegomyia fasciata, and the household mosquito, Culex fatigans. 
In pellagrous territory on three continents are these three mos- 


? Sambon thinks pellagra exists in Scotland, 



238 SILER, garrison: the epidemiology of pellagra 

quitoes. ^ If tlie Simulium were the insect carrier, we should expect 
pellagra in northern as well as southern Europe, in Ireland as well 
as in Italy, in Mnnesota and Canada as well as in Georgia and 
Panama. 

_ Returning now to the ecological and geographical facts of the 
disease, the mosquito accounts for its seasohal relations, periodicity, 
and recurrences; its endemic relations, rural habitat, and sporadic 
appearances in cities; its peculair geographical situation in Africa, 
Europe, and America; its predominance among females and those 
who stay much at home; its attack on all ages and both sexes; 
the spread of the disease in new areas; its first sweep of severity 
in such areas, and later its gradual decrease and the relative im- 
munity of the inliabitants; its presence along streams and in 
mosquito-breeding areas. 

I'\diether a single species of the Culicidm harbor^ the pellagrous 
parasite, as in jmllow fever, or more than one, as in malaria, and 
what this particular species may be, is a question for the future. 
It will probably prove to be a rural breeding, house-living, day- 
biting mosquito. To us and perhaps to those who shall come after 
us the problem remains — ^the investigations, the experiments, and 
the proof. 


AN INTENSIVE STUDY OF THE EPIDEMIOLOGY OP 
PELLAGRA. REPORT OF PROGRESS.^-* 

By Joseph F. Siler, B.S., M.D., 

CAPTAIN, MEDICAL CORPS, DNITED STATES ARMT, 

AND 

Philip E. Garrison, A.B., M.D., 

PASSED ASSISTANT SDRGEON, UNITED STATES NAVE 

(From the Laboratory of Tropical MediciDe, New York Post-Graduate Medical School.) 
(Concluded from page 66, July, 1913.) 


Part II. 

XII. Relative Prevalence, Severity, and Mortality Rates 
IN Recent Years. Pellagra is not a reportable disease in the 
State of South Carolina, nor do the State laws require notification 
of deaths from pellagra to the health authorities. 


H From the Thompson-McFadden Pellagra Commission, New York Post-Graduate Medical 
School and Hospital. 



SILER,, gaheison; the epidemiology of pellagra Zdy 

The data to be analyzed were obtained from a number of sources. 
The 282 cases studied in detail by the Commission afforded one 
source. In the City of Spartanburg, official records are on file 
covering deaths from all causes within the city, and thus it was 
possible to secure accurate mortality statistics for the city. There 
are some five or six undertaking establishments in the county, 
as a whole, and the two establishments in the city of Spartanburg 
sell very nearly all the coffins used throughout the county! These 
two establishments keep on file the names, causes of death, and 
other information concerning the deceased for whom coffins are 
furnished, and they very courteously permitted us to make abstracts 
from their records. From these records we obtained information of 
importance. From the members of the medical profession through- 
out the county we secured much valuable information relating to 
prevalence and mortality rates for 1912 and previous years. From 
pellagrins themselves and from others we were able occasionally 
to obtain information concerning individual cases. Dr. Babcock, 
of South Carolina, kindly furnished us with information covering 
the cases admitted to the State Hospital for the Insane from 
Spartanburg County. 

Although we availed ourselves of all these sources of infor- 
mation, we wish to emphasize the fact that this study is still far 
from complete. We hope, however, to make it more compre- 
hensive and complete during the course of our studies in the same 
county in the summer of 1913. 

The opinion was expressed by many physician's in Spartanburg 
County, that pellagra was not so prevalent in 1912, as was the case 
in 1911. We might say, further, that a like impression prevailed 
in many other parts of South Carolina and in other Southern 
States. 

The statistical data at hand for Spartanburg County are subject 
to analysis in several ways: 

1. From the information available we have determined as nearly 
as possible the actual number of cases of the disease existing in 
the county each year, without consideration of the year in which 
the disease was contracted and without reference to recurrences. 

In 1912 there were 376 cases (minimum). 

In 1911 there were 285 cases (minimum). 

In 1910 there were 115 cases (minimum). 

In 1894 to 1910 there w'ere 114 cases (minimum). 


It is quite evident that pellagra was not recognized as such, to. 
any extent, until the year 1909. 

^ We have endeavored to secure from the practising physicians 
in the county accounts of the first and other early cases occurring 
in their practices. As yet this information is incomplete, but it 
establishes the fact that the disease has existed in the county 



240 SILER, garrison: the epidemiology of pellagra 

sporadically for a number of years. Dr. Dike of Spartanburg, has 
the reeord of a patient dying of pellagra in 1894, although not at the 
time recognized as such. The patient was an adult female, and three 
other members of her family are said to have died of the disease. 
One of the first cases which developed in the city of Spartanburg 
was that of a young woman in a well-to-do family. She contracted 
the disease and died of it in 1902. Dr. Jefferies, of Spartanburg, 
has the record of a patient who died of pellagra, in November, 
1903, but the disease was unrecognized as such until years afterward. 

While there is no doubt that pellagra has existed in this section 
for a number of years, information obtained from the medical 
profession throughout the county indicates very clearly that the 
cases must have been more or less sporadic until within recent 
jmars. The general impression is held that sporadic cases occurred 
until about 1909, at which time there wms a marked increase in the 
number of cases; that during 1910 and 1911 the disease became 
more prevalent; while in 1912 there was a slight decrease in inci- 
dence. The perceptible increase of cases in 1909 may be accounted 
for in part by the fact that the disease was not until then generally 
recognized as pellagra. We have consulted with many medical 
men in Spartanburg County and in other parts of South Carolina, 
and in other States, and it is our belief that the large number of 
cases recognized in 1910 and 1911, as compared ivith the number 
recognized previous to that time, cannot alone be explained on 
a basis of general failure to recognize the disease in earlier years. 
Non-recognition 'unquestionably explains some of the increase, but 
we are thoroughly convinced that there has been an actual and 
quite perceptible increase in the number of cases wathin the past 
three or four years. 

2. A seeond analysis of our data shows that the minimum number 
of cases of pellagra in Spartanburg County from 1894 to October, 
1912, was 495. This is obviously a conservative estimate, as prior 
to 1911 our data are made up largely of eases in whieh the disease 
terminated in death. 

3. We have endeavored to determine the aetual number of new 
cases of the disease occurring each year. It is possible to determine 
this with a reasonable degree of accuracy for 1912 and with a 
fair degree of accuracy for 1911, but prior to that time the incidence 
rates (annual) are altogether a matter of conjecture. We have 
seen that there wmre at least 376 cases of pellagra in Spartanburg 
County in 1912. Of the cases seen during our study in 1912 (282), 
97 contracted pellagra in 1912, and of 94 others not included in our 
series we have knowdedge of the fact that 16 contracted the disease 
in 1912. The minimum total of new^ cases for 1912 is thus 113. 
In 1911 the total number of cases in the county wms 285. Among 
the cases included in our series (282), 100 contracted 

1911, and we have record of 20 other cases contracting it in IPU, 



SILER, garrison: the epidemiology of pellagra 241 


making a total of 120. Of the remaining 165 cases existing in the 
county in 1911 the information at hand is more or less indehmte, 
but unquestionably some of this number contracted the disease 

in 1911. , . 

Prior to 1911 definite statistics are too meagre to warrant analysis. 
Our statistics suggest that pellagra, so far as new cases are concerned, 
was somewhat more prevalent in 1911 than in 1912. 

The annual case death-rate among pellagrins was as follows: 


Year. 

No. of 
deaths. 

Unknown 

8 

1894 

1 

1898 

1 

1899 

1 

1901 

2 

1902 

2 

1903 

1 

1904 

1 

1908 

2 

1909 

14 

1910 

32 

1911 

54 

1912 

47 


No. of Per cent, of 
cases. deaths. 


25 114 22 


115 28 

285 19 

376 12 


It should be understood that these mortality statistics are of 
pellagrins who have died from all causes, not deaths from pellagra 
alone. In a number of these cases the pellagrous symptoms were 
of but little moment, the actual causes of death being other factors, 
among which may be mentioned tuberculosis and senility. The 
morbidity and mortality statisties for 1910 and the years preceding 
are not sufficiently complete to warrant any deductions. Those 
for 1911, showing 19 per cent, deaths, and for 1912, showing 12.5 
per cent, deaths, represent more nearly the relationship between 
the morbidity and mortality rates as they exist at present. 

Death during the initial attack is not uncommon. In the series 
of 282 cases studied by this Commission, 97 contracted the disease 
in 1912, and 5 of these cases died during the initial attack. 

Summary. The following general statements concerning relative 
. prevalence and mortality seem to be warranted: 

Sporadie eases have been observed in Spartanburg County 
since 1894. During the past three or four years there has been 
an alarming increase in the number of cases. The number of neiv 
cases developing in 1911 was somewhat greater than in 1912, 
although the difference was but slight, l^ffien the disease first ap- 
peared in Spartanburg County the symptoms were frequently 
severe and the death-rate appears to have been high. The number 
of cases in the county is increasing while the death-rate appears 
to be decreasing. 

XIII. Clinical Observations on Pellagra. A. Chronicity 
and Periodicity, with a Study of the Influence of Clwiatic Conditions. 
1. Chronicity. Y\'e have observed no differences in the sympto- 
matology, and more particularly in the chronicity, of the disease as 



242 SILER, garrison; the epidemiology of pellagra 

it exists in this country and in Italy, except the fact that the 
mortality rates in this country two or three years ago were appar- 
ently much higher than those obtaining in Italy at the same time. 
A few of the cases in the present series died during the initial 
attack in 1912, while others presented a wide gradation of symptoms 
ranging from those involving the cutaneous, gastrointestinal, and 
nervous systems to those in which the cutaneous system alone 
was involved. 


Original Attack and Annual Recurrences. 

Early history indefinite: recurrence, 1912 

1904. 

Firstattack,1904;recurrcnce3, 1903, 1900,1907, 1908, 1909, 1910, 1911, 1912 . . . , 

1905. 

Indefinite history, 1905 to 1911 inclusive; recurrence 1912 

First attack, 1905; recurrences, 1906, 1907, 1908, 1909, 1910, 1911, 1912 

1906. 

First attack, 1906; recurrences, 1907, 1908, 1909, 1910, 1911, 1912 

1907. 

First attack, 1907; recurrences, 1908, 1909, 1910, 1911, 1912 

First attack, 1907; no clear history, 1908, 1909, 1910; reourrenecs, 1911, 1912 . . . . 

J908. 

First attack, 1908; recurrences, 1909, 1910, 1911, 1912 

First attack, 1908; recurrences, 1909, 1910; no recurrence, 1911; recurrence, 1912 . 

First attack, 1908; no recurrences, 1909, 1910: recurrences, 1911, 1912 

First attack, 1908; recurrence, 1909; no recurrence, 1910, 1911, 1912 

1909. 

First attack, 1909; recurrences, 1910, 1911, 1912 

First attack, 1909; indefinite history, 1910, 1911; recurrence, 1912 

Indefinite history, 1909, 1910, 1911; recurrence, 1912 

First attack, 1909; no recurrence, 1910; recurrence, 1911; no recurrence, 1912 .... 

First attack, 1909; no recurrences, 1910, 1911, 1912 

First attack, 1909; recurrences, 1910, 1911; no recurrence, 1912 

First attack, 1909; no recurrences, 1910, 1911; recurrence, 1912 

First attack, 1909; recurrence, 1910; no recurrence, 1911; recurrence, 1912 

1910. 

First attack, 1910; recurrences, 1911, 1912 - ■ 

First attack, 1910; no recurrence, 1911; recurrence, 1912 

First attack, 1910; recurrence, 1911; no recurrence, 1912 

Indefinite history, 1910; recurrences, 1911, 1912 

First attack, 1910; no recurrence, 1912 

First attack, 1910; no history, 1911, 1912 

1911. 

First attack, 1911; recurrence, 1912 

First attack, 1911; no recurrence, 1912 

Indefinite history, 1911; no recurrence, 1912 

Indefinite history, 1911; recurrence, 1912 


First attack, 1912 


1912. 



Total 


. . 277 



SILER, garrison: the epidemiology of pellagra 243 

It will be noted that in some of these cases the disease was 
contracted originally in 1904; in others, in 1905 and every,- year 
thereafter to 1912, inclusive. Oecasionally the history of previous 
attacks was indefinite, and such cases are so classified. 

In this series there are 55 cases of pellagra recognized from one 
to five years ago by the attending physicians in which the annual 
recurrence has failed to appear in one or more seasons. In^ some 
of these cases the disease has reappeared after an intermission of 
one or two years, while in other instances symptoms have been 
present for one or more seasons, and have never since recurred. 
The following cases illustrate this point: 

First attack, 1908; recurrence, 1909; no recurrences, 1910, 1911, 1912 1 

First attack, 1909; no recurrences, 1910, 1911, 1912 I 

First attack, 1910; no recurrences, 1911, 1912 3 

In addition to these five cases we have records of a few other cases 
in Spartanburg County, not included in this series, in which patients 
have been without symptoms for a period of two, three, or more 
years and appear to be cases of recovery from the disease. 

Our individual case histories show that a number of adult females 
have borne children since contracting pellagra, but in only 22 cases 
is the relationship of the pregnancies to the development of symp- 
toms sufficiently definite to warrant analysis. In 16 of these cases 
(75 per cent.) there were no symptoms of pellagra during pregnancy. 
These observations cover only a small number of cases, and this 
subject will be investigated more in detail in this series and in 
additional ones during the summer of 1913. Pregnancy seems to 
show a tendency to inhibit the development of pellagrous symptoms. 

2. Periodicity. A study of the literature of pellagra gives one 
the impression that there is a definite seasonal periodicity. We are 
led to believe that the disease appears in the spring; that there is 
a relative decrease in the number of cases in midsummer; that a 
fall recrudescence occurs, and that there is a tendency for symp- 
toms to reappear at the same time each year. 

Sambon cites the spring and fall periodicity as a strong argument 
in favor of his hypothesis that the disease is of protozoal origin 
and transmitted by a blood-sucking insect, a species of Similium. 

We have undertaken some studies bearing on this phase of the 
subject. It is evident that these observations, except for the year 
1912, must be based on the statements of patients suffering with 
pellagra. We have endeavored to control such statements and to 
add to their reliability by information obtained from other members 
of the household, and more particularly by that obtained from the 
attending physician. The cases will first be considered by month 
of onset of symptoms. Chart 9 represents graphically the month 
of onset of symptoms arranged by years. It is understood, of 
course, that this chart represents not only the month of original 



244 SILER, garrison: the epidemiology of pellagra 

onset in each case, but includes also the recurrences in each case 
j^ear by year. 



Chart 9. — Month ot onset of original attack and all annual recurrences (277 eases). 



Chart 10. — Month of original onset in cases developing in 1911 and 1912. 


In Chart 10 we have analyzed further the 1911 and 1912 cases 
from the standpoint of original onset of symptoms when the dis- 
ease was contracted. It is evident from these charts that cases 
begin to show symptoms in the early spring, that there is a gradual 
increase in the number showing symptoms until the month or 
June, when the incidence curve reaches its highest point, and that 
after the month of June the incidence-rate falls quite rapidly. It 
is also evident that there are no spring and fall recrudescences ot 
pellagra in Spartanburg, County. On the contrary, cases begin 
to show symptoms in the spring, increase in number until mid- 
summer, and then rapidly decrease. 



SILER, garrison: the epidemiology of pellagra 

We have analyzed the recurrent attacks with a view of deter- 
mining whether or not there was any marked tendency in each 
individual case for active symptoms to appear during the same 
month year after year, with the following results; 

Interval between Onset of Successive Attacks. 

11 to ni4 




months or 

Less than 11 


\\]4 to 123 ^ 

12}^ to 13 

or more than 


months. 

months. 

13 months. 

Cases contracting pellagra in 1909 

. ... 4 

2 

5 

Cases contracting pellagra in 1910 

. . , 12 

17 

10 

Cases contracting pellagra in 1911 

. . . . 21 

20 

24 


37 

39 

39 


We have analyzed still further the uniformity of recurrences, 
first by ascertaining the date of appearance of symptoms in indi- 
viduals who contracted the disease in 1910 and comparing these 
dates with date of recurrence of symptoms in the same individuals 
in 1911, and second, by tabulating the same facts for cases develop- 
ing originally in 1910 and 1911 and recurring in 1912. 

Among the cases showing symptoms originally in 1910 the re- 
currence in 1911 was a month or more earlier in 14 cases, during 
the corresponding month in 27 cases, and a month or more later 
in 17 cases. Among the cases contracting the disease in 1910 
and 1911 the recurrence in 1912 was at least a month earlier as 
compared with the appearance of symptoms in 1911 in 36 cases, 
during the same month in 48 cases, and at least a month later in 
33 cases. 

It is evident from this analysis that there is no particularly 
marked tendency for the seasonal recurrences to reappear during 
the same month year after year. 

3. Influence of Climate, Climatic conditions are said to influence 
the periodicity of the disease. If during the spring months the 
precipitation is high, temperature low, and number of rainy days 
excessive, there is said to be a delay in the appearance of acute 
symptoms, more particularly those involving the skin. One of us 
had occasion to observe this influence in the spring of 1910 while 
investigating conditions in northern Italy. In March and April 
of that year the weather conditions in the provinces of hlilan 
and Bergamo w^ere quite unsettled, precipitation was excessive, 
there were many rainy days, but little sunshine, the temperature 
was low and the atmosphere was damp and chilly. At this time 
there were but few cases showing active symptoms of pellagra. 
The delay in appearance of active symptoms was attributed to 
unsettled weather conditions. We were informed, further, that 
it had been observed for many years that unsettled weather con- 
ditions in the spring always delayed the appearance of active 



246 SILER, garrison: the epidemiology of pellagra 

symptoms of the disease. We have been able to compare this 
general impression as regards conditions in Italy with similar 
conditions in the South. ^ Early in May, 1912, we investigated the 
prevalence of pellagra in different sections of South Carolina, 
in North Carolina, and in Georgia. The physicians consulted 
informed us that there was a delay in appearance of cases showing 
active symptoms, and that whereas in April, 1911, they had ob- 
served many such cases, in April, 1912, they had seen but few. 
We were informed that spring and settled weather conditions were 
present much earlier in 1911 than was the case in 1912. This 
general impression is confirmed by the fact that farmers in the 
states mentioned were able to get their crops under way quite early 
in 1911 wlrile in 1912 they were delayed for from three to six 
weeks. In Spartanburg County it was possible to secure much more 
detailed information covering weather conditions. The general 
information given us is in agreement vdth that outlined above. 

In order that these general impressions may be controlled, we 
have obtained from the United States Weather Bureau its 
reports on weather conditions in Spartanburg County, South 
Carolina. The available information from this source, which 
includes monthly precipitation, montlily mean temperature, and 
number of rainy days, is presented in Charts 11, 12, and 13. 

It is evident from an analysis of the monthly precipitation curves 
for 1911 and 1912 that in 1912 during the months of January to 
June inclusive, except for the month of April, the monthly pre- 
cipitation was greatly in excess of that for the like period in 1911. 

Analysis of the monthly mean temperature curve for 1911 and 
1912 shows that in 1912 for the months of January to June inclusive 
the temperature was, in general, appreciably lower than was the 
case for like months in 1911. 

A study of Chart 13 (number of rainy days) shows that for the 
first six months in 1912, except for the months of March and April, 
the number of rainy days per month was in excess of the number 
for the like period in 1911. WhUe there were more rainy days in 
March and April, 1911, than for the same months in 1912, the 
amount of precipitation for these two months in 1912 was m 
excess of that for 1911. 

These charts, considered as a whole, indicate quite clearly that 
settled weather conditions with relatively high temperature and 
low precipitation existed in Spartanburg County at an earlier date 
in 1911 than was the case in 1912. 

The relationship between climatic conditions existing in 1911 
and 1912 and the appearance of acute symptoms of pellagra can 
be determined by referring to Charts 9 and 10. There was quite 
a definite tendency for symptoms to appear at an earlier date m 
1911 than was the case in 1912. The incidence-rate in both charts 
was high for the month of April, 1911, while in 1912 the incidence- 



SILER, garrison: THE EPIDEMIOLOGY OF PELLAGRA 24/ 

rate for April was comparatively low, especially in respect to new 
cases, and the maximum rate was not attained until the month or 
June. 



Chakt 12. — ^Monthly mean temperature. 



248 SILER, garrison: the epidemiology of pellagra 

Stouiary. 1. Chronicity. In a large proportion of the cases 
in this series the disease exliibited marked chronicity. In 20 per 
cent', the annual recurrences had failed to appear in one or more 
seasons. Pregnancy seems to show a tendency to inhibit the develop- 
ment of pellagrous symptoms. In 2 per cent, of the cases no symp- 
toms had been present for from two to three years, and these 
appear to be cases of recoverj’’ from pellagra. 

2. Periodicity. Cases begin to show symptoms in the early 
spring, increase in number until midsummer, and then rapidly 
decrease. There was no evidence whatever pointing to any spring 
and fall recrudescences, so frequently referred to in the literature 
of pellagra. There is no particularly marked tendency for the 
seasonal recurrences to appear during the same month, year after 
year, in the same individual. 

3. Influence of Climate. Climatic conditions appear to influence 
the development of symptoms of the disease. If during the spring 
months precipitation is high, temperature low, and number of 
rainy days excessive, the appearance of acute symptoms, more 
particularly those involving the skin, is delayed. 

B. Symptomatology of 1912 Attacks. A considerable amount of 
information has been collected in reference to symptomatology, 
but a discussion of this phase of the subject will not be undertaken 
until we have followed these cases through their 1913 recurrences. 

The following general statements are warranted : Wliile three or 
four years ago it was quite the usual thing to see patients showing 
a combination of severe skin lesions, severe stomatitis, intractable 
diarrhea or dysentery, mental derangement, and physical exhaus- 
tion, comparatively few patients exliibiting this symptomatology 
in a marked degree were observed in Spartanburg County during 
the summer of 1912. In many of the cases observed the sj'^mptoms 
were quite mild, and frequently they were confined almost entirely 
to the cutaneous system. This apparent indication of a decreasing 
virulence of the disease is strengthened by certain facts which appear 
in the study of mortality rates of pellagra in Spartanburg County 
for 1912 and earlier years. 

XIV. Clinical Observations upon Economic Status and 
Previous Health of Pellagrins. It is believed by many who 
are brought into contact with pellagra that predisposition plays 
an important part in its development and that the disease most 
frequently affects the poorer classes, who live under unfavorable 
hygienic conditions and who subsist on a diet of low nutritive 
value and of limited variety. Some detailed studies were unde^ 
taken covering these points. The general hygienic conditions and 
dietary will be discussed elsewhere, and this section will be confined 
to a consideration of financial circumstances and health conditions 
as possible predisposing factors. 



siLEE, gabrison; the epidemiology of pellagra 249 

A. Economic or Financial Circumstances. Iii_ recording^ the 
data relating to the economic conditions under which the patients 
lived, the following classification was adopted: squalor, poverty, 
necessities, comfort, affluence. These terms are somewhat arbitrary 
and necessitate some brief explanation. 

Squalor. Cases so classified are confined to those living in wooden 
huts in poor repair and without out-houses. Their diet was ex- 
tremely poor and without variety, living rooms squalid, clothing 
filthy aiid in rags. 

Poverty. Cases of this class lived in cabins usually without 
out-houses, rather isolated, ordinarily on large plantations. ^ Food 
consisted largely of bacon, molasses, corn-bread, and biscuit. 
Negroes of the poorer tenant class form this group very largely. 

Necessities. This class included those instances in which the 
family had a fairly regular cash income sufficient to provide for 
actual needs. It is made up largely of mill operatives and their 
families. They live in cottages, with some land about them, but 
rather closely aggregated to form mill-villages. 

Comfort. Cases classified in this group are made up largely 
of farmers who own their own plantations and stock, have a good 
diet, and are in comfortable financial circumstances. 

Affluence. In this group are included patients who live under 
the best of hygienic and financial conditions. Their houses are 
well-constructed, usually screened, and their diet is well balanced. 

The cases so classified number 277 and are divided as follows: 


Squalor 2 

Poverty 28 

Necessities 200 

Comfort 41 

Affluence 6 


It will be seen that in 83 per cent, of the cases (squalor, poverty, 
necessities) the economical conditions were poor; that in 15 per 
cent, (comfort) the economical conditions were within the average, 
and in 2 per cent, (affluence) the financial circumstances were 
well above the average. 

In connection with the “affluence” group, it may be said that the 
members^ of the Commission have personal knowledge of a number 
of other instances in which pellagra has developed in persons living 
under the best of hygienic and economic conditions. 

Grouping the cases under two general subdivisions, we find 
that in 83 per cent, of the cases the economic conditions are poor, 
while in 17 per cent, they are good. 

B. Diseases of Childhood ard General Health in Childhood. Dis- 
eases of Childhood. In considering the diseases of childhood the 
cases were dmded in turn groups: (1) those gi\ang a history of 
one or more of the following diseases: measles, mumps, chickenpox, 

VOL. 140, NO. 2. — AUGUST, 1913 9 



250 SILER, garrison: the epidemiology of pellagra 

and whooping cough; (2) those giving a negative history for the 
diseases of childhood. The data covered 270 cases. 


Diseases of Childhood. 

Cases giving a historj- of one or more of the following diseases of childhood: measles, 


mumps, whooping cough, and chickenpox 252 

No history of diseases of childhood 

Total 270 


As permanent injury to the heart and kidne 3 '^s not infrequently 
follows attacks of scarlet fever, this disease was considered separ- 
ately. In 20 cases a history of scarlet fever was elicited. 

General Health in Childhood. The classification adopted in the 
consideration of general health in childhood was the following: 
Good, fair, and poor. Inquiries covering this point were made in 
270 cases. Of this number, 232 (86 per cent.) gave a history of good 
health during childhood; in 28 cases it was fair, and in 10 cases 
it w'as poor. 

C. Diseases of Admit Life and General Health during Adult Life. 
Diseases of Adult Life. The total number of cases considered is 
198. The diseases peculiar to female adult life wall be considered 
in a separate table. The following summary’’ show's the prevailing 
diseases in some detail: 

No. of oases. 


Gastric disturbance 

Dysentery, acute or chronic . . 28 

Typhoid fever 46 

Tuberculosis 7 

Other diseases, unclassified 36 

No history of ill health 

Total 198 


An analysis of diseases of adult life show's that 34 per cent. (67) 
of the total number of cases gave no history of ill-health. In 25 
per cent, of the cases, those giving history of gastric disturbances, 
dj'senterj', and tuberculosis, a chronic disease was present. 

General Health in Adult Life. In considering this point the classi- 
fication adopted was that of good health, fair health, and poor 
health. 

General Health during Adult Life. 

Good 

Fair 

Poor 


An analj'sis of the data concerning general health condi ions 
during adult life shows a history of good health in 62 per cen ., 
fair health in 30 per cent., and poor health in 8 per cent. 


. . 134 

. . 66 
. . 18 



SILEE, garrison: the 


EPIDEMIOLOGY OF PELLAGRA 251 


D. Obstetrical and Gynecological History. 

Social Status. 

Married 

Widowed 

Sincle 

184 

Obstetrical History. 

/ 

Married females who have borne children 
Unmarried females who have borne children 
Married females who have not borne children 
Unmarried females who have not borne children 


184 

28 

20 

21 

25- 

16 

8 

10 

4 

3 

1 


Number of females who have borne 1 child 
Number of females who have borne 2 children 
Number of females who have borne 3 children 
Number of females who have borne 4 children 
Number of females who have borne 5 children 
Number of females who have borne 6 children 
Number of females who have borne 7 children 
Number of females who have borne 8 children 
Number of females who have borne 9 children 
Number of females who have borne 10 children 
Number of females who have borne 11 children 


136 

2 

23 

23 


Average number of children borne = 3.8. 


138 


Menstruation during Period op Acute Pellagrous Symptoms. 


Normal 95 

Irregular S 3 

Excessive 6 

Suppressed 10 

Menopause H 

No information g 


Diseases of Women. 


184 


Number of females giving more or less definite history of ovarian, uterine, or 
other pelvie disease 


From this summary it will be noted that among the females who 
had attained the age of puberty, 86 per cent, of the cases occurred 
in married women, and that 86 per cent, of these married women 
had borne children. The greatest number of children borne by 
an individual is 11. The average number borne is 3.8. We have 
collected some statistical information in reference to the average 
size of families in mill-villages in Spartanburg County, from the 
standpoint of children borne by each woman, and it is not signifi- 
cantly different from the average number shown among pellagrous 
women. 

The amount of time at our disposal and the relative importance 
of the subject did not warrant examinations of sufficient thorough- 
ness to classify in detail the diseases of women. Of the 49 cases 



252 SILER, garrison: the epidemiology of pellagra 

giving history of such diseases the following were noted: tubal 
and ovarian inflammation, pus-tubes, cystic ovary, endometritis, 
uterine fibroid, carcinoma of the uterus, displacement of the uterus, 
and pelvic inflammation. In a number of cases, symptoms refer- 
able to the genital tract were quite indefinite. 

The feature of most interest and relative importance in the 
consideration of predisposing factors is the chronologic relationship 
of previous illness to the development of pellagrous symptoms. 
The following summary gives in some deatil the information secured: 

Recent Illness Possibly Predisposing to Pellagra. 


Gastric disturbance (including chronic gastric indigestion) IS 

Dysentery (chronic during summer) 23 

Diarrhea 6 

Hookworm disease (moderate infection) 1 

Ovarian cyst (large) 1 

Uterine disease 4 

General poor health (usually following childbirth) 30 

Nephritis 3 

Ascites (probably due to nephritis) 1 

Valvular disease of the heart 1 

Asthma 1 

Pulmonary tuberculosis 7 

Malarial fever 1 

Alcoholism I 

Morphine habit 1 

Infantile paralysis 1 

Whooping cough 2 

Measles 12 

Chiekenpox 1 

No history of recent illness, 15G \ ^ 

Health better than usual, 2 / 


270 

In 15 of the cases a history of chronic indigestion was obtained. 
In explanation of these cases it may be said that symptoms of 
gastric disturbance preceded the active cutaneous symptoms of 
pellagra by a period of several months to several years. In 11 per 
cent. (30) of the cases no history of illness immediately preceding 
the development of pellagra could be obtained other than the fact 
that the general health was poor. Quite frequently this history 
of poor health followed confinement. One history of hookworm 
disease is included. This case showed objective clinical evidence 
of hookworm infection, which was uncommon for Spartanburg 
County. Malarial fever does not appear to be endemic in this 
county, and the one case included in this table was contracted in 
one of the “low country” counties. We were impressed with the 
fact that children not infrequently contracted pellagra during con- 
valescence from acute infectious diseases, or very soon thereafter. 
It will be noted that 15 such observations were made:^ whooping 
cough, 2; measles, 12; chiekenpox, 1. Of the 43 cases in children 
under ten years of age, 11 (approximately 23 per cent.) gave a 



SILER, garrison: THE EPIDEMIOLOGY OP PELLAGRA 253 

history of measles. In most of these the attack of pellagra occurred 
soon after recovery from measles. _ 

Summary. In the large majority of these cases (83 per cent.) 
economic conditions were poor, and the disease is most prevalent 
among people of insufficient means. We would, however, invite 
attention to the fact that 17 per cent, of these cases occurred in 
patients living in comfortable circumstances. This is not in agree- 
ment with Italian conceptions of the disease, where it presumably is 
confined altogether to the poorer element of the general population. 

An analysis of general health conditions during childhood shows 
that in 86 per cent, of the cases the history was that of good health. 
So-called congenital diseases and inherited constitutional defects 
were of no apparent significance. 

An analysis of diseases of adult life shows that in 25 per cent, of 
the cases, those giving a history of gastric disturbances, dysentery, 
and tuberculosis, a chronic disease was present, and it might be 
inferred that there is evidence of existing predisposition. During 
adult life the general health conditions were good in more than 
half the cases (62 per cent.). 

An analysis of the obstetrical and gynecological data shows that 
among females who had reached the age of puberty, those most 
affected were married women (86 per cent.). As 86 per cent, of 
the married women had borne children and the average number of 
children borne was 3.8, it might be inferred that childbearing is 
an important predisposing factor. We know, however, that the 
average number of children borne by married women in the general 
population of the South is equal to or even greater than this. 

Recent illnesses do appear to be worthy of serious consideration 
as predisposing factors, and it is our opinion that they frequently 
do influence not only the development of pellagra but also the 
severity of the attacks. It will be noted, however, that 59 per cent, 
of the cases in this series gave no history of illness immediately 
preceding the development of pellagra. 

XV. Studies upon Hygienic and Sanitary Conditions of 
Houses and Premises. A. Houses. The prevailing type of home 
in this county is a frame dwelling. The site usually is well drained, 
and there is^ always more than sufficient space between houses to 
afford free circulation of air. 

In this study the dwelling houses are considered in three groups: 
brick, frame, and cabin. 

Brick Dwellings. Dwellings of brick construction are relatively 
few in number. The mercantile houses in the larger centres are 
usually of brick construction, one or more stories in height, and the 
upper stories occasionally are used for living quarters. One of 
the cases included in this series was occupyiug such quarters. 

i^rame Dwellings. The mill-village dwellings are of the same 
general type, usually one story, sometimes two (Figs. 1, 2, 3, and 4). 



254 SILER, garrison: the epidemiology of pellagra 


The houses are almost always double. The single-story houses 
consist of a combination sitting and bed room, dining room, and 



Fig. 1. — TjT)ic.al milM’illaEc house. 



Fig. 2 — Tj-pical miU-village house. 

kitchen (Fig. 5). In the two-story houses there is in addition 
a bed room on the second floor. Small families occupy one-hair 






SILER, garrison: the epidemiology of pellagra 255 


of a double single-storj'^ house, and large families live in either a 
two-story house or both sides of a double one-story house. There 
are two or three windows in each room and a small porch in front. 
These houses have no cellar, the foundation is brick, the ground 
floor is well above the ground, and the space between the ground 



Fig. 3. — Typical mill-village house 



Fig. 4.— Typical miU-\'illagc house. 


ground floor is ieft open, permitting free circulation of nlr 
Doors are placed directly in line from trort to rear the house 

^ walls and ceiling. The timber used for tliis purpose 
sometimes matched, sometimes not The roof has a good phch 





256 SILER, garrison: the EPIOEMIOLOGy OP PELLAGRA 


with a large attic, permitting circulation of air, and the bed rooms 
have open fireplaces which further improve ventilation. 

These houses are practically all infested with Cimex, and the 
grooves between the boards used in sealing the rooms afford an 
ideal place for the hatching out of broods of these insects. 



Fig. 6. — ^Type of farm-house and well. 


The dwelling houses in the farming section are practically always 
frame houses (Fig. 6). Many of the farm-houses, more particularly 







SILER, GARRISON'. THE EPIDEMIOLOGY OF PELLAGRA 257 

those occupied by owners, are well-constructed, roomy, and superior 
to the mill-village dwelling-house. On the other hand the usual 
tenant-house is inferior in many respeets to that found in mill- 
villages. 

Cabins. In this group are included the small frame or log 
dwellings, poorly constructed and ill-ventilated (Fig. 7). The 
negroes of the farming class usually occupy such houses. 



Fio. 7 — Type of cabin occupied by negro tenants on farms. 


Hygienic and Sanitary Condition of Houses. 

Brick 

Frame 

C.abin 


Repair; Good 
Poor 


Screened: Yes 
No 


Ventilation: Good . 

Fair . 
Poor . 


2 

230 

19 

257 

212 

38 

250 

21 

229 

250 

155 

80 

8 

249 

142 

92 

12 


General cleanliness: Good 
Fair , 
Poor . 


240 





258 SILER, GARRISON; THE ERIDEMIOLOGY OF PELLAGRA 


Summary. 92 per cent, of the cases lived in frame houses of fairly 
good size, and 85 per cent, of the houses investigated were in 
fairly good repair. Nine per cent, of the houses were sereened, but 
in many instances the screening was more or less unsatisfactory. 
In only a small proportion of the screened houses did the screening 
afford satisfactory protection against the ingress of insects. Musca 
domestica was present in all, and Stomoxys calcitrans was present 
in many unprotected houses. 

Ventilation. In 62 per cent, of the houses investigated, venti- 
lation of the bed rooms w^as good, in 36 per cent, only fair, and in 
3 per cent. poor. The number of persons occupying each bedroom 
averaged about tliree, and the available allowance of air space did 
not, in general, suggest overcrowding. Poor ventilation and over- 
crowded conditions were more in evidence in the negro population. 

Summary. We have failed to find anything of significance in 
connection with the houses from the standpoint of overcrowding 
and ventilation. It was observed that Musca domestica was 
always more or less abundant, and that of the blood-sucking insects, 
Stomox 5 '’s calcitrans and Cimex lectularius were of common occur- 
rence. A detailed study of the observations on insects udll be 
considered in the entomological section of this report, 

B. Water Stipply. The sources of water supply for drinking 
purposes among the general population of Spartanburg County are 
similar to those considered in this study. For analytical purposes 
the sources of supply are divided into three groups, wells, springs, 
and city water. 

Source of Water Supply. 

Wells: Dug Tvell, with bucket .... 162 

Artesian well, with pump ... 30 . . . 192 

Springs 13 . . . 13 

City water, hydrant 30 . . . 36 . . - 241 

Protection of Water-supply with Reference to Contamination by 
Surface Water or by Seepage at Point from Which Supply 

IS Dravti. 

Protection satisfactory (water-supply drami from hydrants, 
from artesian wells with concrete base, or from deep 

wells with concrete base) 

Partly protected (water-supply drawn from wells with wooden 
base, either covered or uncovered, or from isolated 
springs) 

241 

Wells. The wells are of several types. The type most common 
in rural districts and in some of the mill-villages is the ordinary 
dug wmll, about five feet in diameter (sometimes round and some- 
times square), from thirty to sixty or more feet in depth, and 
protected at the top by a wooden frame. Though a few wells^ could 
be classified as “shallow wells,” it was quite the usual thing to 






260 SILER, garrison: the epidemiology op pellagra 

find that the supply was obtained from a sufficient depth to insure 
that an impermeable stratum supervened, preventing contamina- 
tion by surface water. 



Fig. 10. — Tj-pfi of bucket well, wooden base 



Fig. 11. — Type of driven well with pump. Sloping concrete base. 


The water was usually drawn by means of the well-knovm bucket 
and windlass arrangement, but in a number of instances pumps were 





SILER, garrison; the epidemiology of pellagra 261 

in use. In tke farming districts, ordinarily,^ no effort was made 
to guard against contamination at the immediate source oi supply, 
but in some of the mill-villages these wells have concrete bases, 
sloping outward. The various types of wells can be better under- 
stood by reference to Figs. 8, 9, 10, 11, and 12. ^ 

In some of the mill-villages, artesian wells are m use. These 
artesian wells are usually quite deep, and the water is drawn by 
pump. 



FiQ. 12. — Dug vrell with bucket. Concrete base. 


Springs. The use of spring water was, with one or two exceptions, 
confined strictly to the farming population living in comparative 
isolation. Usually drainage from the house was not in the direction 
of the spring, and the possibility of contamination was not a factor 
of importance. 

City Water. This source of supply was confined to the city of 
Spartanburg. Bacteriological and chemical examinations are made 
from time to time, with no evidence of contamination. 

Summary. It will be noted that 80 per cent, of the cases used 
well water; 15 per cent, used city water; and 5 per cent, used 
spring water. 

In 27 per cent, of the total observations (241) the water supply 
was perfectly protected from contamination. The remaining 73 
per cent, are classified as partly protected, but this group requires 
some further explanation, as otheruise an erroneous inference 
might be drawn. We have included in this group all springs, all 
shallow wells, and all wells without a concrete base. As a matter 



262 SILER, garrison: the epidemiology of pellagra 


of fact, there were few shallow wells, and the probability of con- 
tamination in this group, considered as a whole, was but slight. 

We realize that the water-supply is not considered to be of any 
importance as a factor in the etiology of pellagra. In this study, 
however, we have endeavored to investigate, as far as was possible, 
all probable factors concerned in the epidemiology of the disease, 
and for this reason have considered the water-supply. We have 
found nothing of any apparent significance in this connection. 

C. Disposal of Excreta. In making a general survey of sanitary 
conditions, a study of the disposal of excreta was included. 
In classifying privy types we have adopted, for the sake of con- 
venience, the classification used by the Rockefeller Sanitary Com- 
mission in its hookworm investigations in tlie Southern States. 

Ix-DEX OF Types Adopted by t he Rockefeller Sanitary Commission. 


Per cent. 

Class A. Water carriage or Marine Hospital Barrel (L. R. S.) . . . . 100 

Class B. Water-tight and rigidly dy-proof privy 75 

Class C. Water-tight, closed-in back 50 

Class D. Closed-in back, surface prh'j- 25 

Class E. Ordinary open-in-back surface privy 10 

Class F. No pri^-y 00 


We encountered in this study one type of privy not falling 
strictlj'- in any of these groups. The t^Tie in question (Fig. 14) 
was found in three or four of the mill-villages, and consisted of 
an out-house open in front and behind. The excreta were collected 
in square metal pails, supposedly water-tight. These pails were 
emptied at intervals. No attempt vras made to keep out flies, 
the pails were frequently battered, and not water-tight, and usually 
were extremely filthy. It wms not possible to include these privies 
in Class C, nor wms it fair to put them in Class E. We have there- 
fore placed them in Class D. 

The following tables will sho^v the facts observed: 

Pbiat Types. 

.... n 
.... 0 

!!!!!!!! : 0 

51 

. . 152 

. . 29 


Class A 
Class B 
Class C 
Class D 
Class E 
Class F 


Sanitary Index for all Privies. 

Class A. 11 at 100 per cent 

Class B. 00 at 75 per cent 

Class C. 00 at 50 per cent 

Class D. 51 at 25 per cent 

Class E. 152 at 10 per cent 

Class F. 29 at 0 per cent 


1100 

00 

00 

1275 

1520 

00 


Total 


Sanitarj’ index = 16. 


. 3895 



SILER, GARRISON’. THE EPIDEMIOLOGY OF PELLAGRA 263 


Distance of Privy from House. 


10 yards 

15 yards 

20 yards 

25 yards 

30 yards 

35 yards 

40 yards 

45 yards 

60 yards 

60 yards 

70 yards 

75 yards 

100 yards 

200 yards 

Water-carriage system (Class A) 
No privy (Class F) . . . . 


4 

9 

35 

25 

75 

4 

9 

1 

31 

2 

1 

1 

2 

1 

11 

29 


Total 


240 


Distance of Privy from Well. 


10 yards " 

15 yards ' . . . 6 

20 yards ' 13 

25 yards 7 

30 yards 27 

35 yards 

40 yards 12 

50 yards 45 

60 yards 5 

70 yards 6 

75 yards 9 

80 yards 1 

85 yards 1 

100 yards 5 

110 yards 1 

250 yards 1 

Water-carriage system (Class A) . . . . 11 

No privy (Class F) . 29 


Total 


190 


The cases in which the disposal of excreta was by water carriage 
(5 per cent.) were confined to the city of Spartanburg. No privy 
of the Marine Hospital type (L. R. S.) was observed. Between 
30 and 40 cases of pellagra developed in the city of Spartanburg in 
other than mill-village sections. Only 8 of these cases used a water- 
carriage system of disposal of excreta. There were no privies of 
Class B or C. In 21 per cent, the privies were arbitrarily included 
in Class D. In 63 per cent, of the cases the method of disposal was 
that of the unhygienic and insanitary open surface privy, and in 
12 per cent, of the cases no privy wrs used. 

The method of disposal of excreta in the mill-villages, located in 
Spartanburg County falls under two classes, D and E (Figs. 13, 
14, 15, 16, and 17) ; In some villages the pail system is in use, but 
beneficial results are negatived by the fact that no effort is made 
to screen the closets properly either in front or behind. In other 



264 SILER, garrison; the epidemiology of pellagra 


villages the unhygienic open surface privy is in use, and flies have 
free access to large collections of excreta in close pro ximi ty to the 
dwelling-houses. In some mills the privies are cleaned weekly; 



Fia. 13. — Privy, Typo E. Surface, unscreened. 



Fig. 14. — ^Privy, Type D. Pail system, unscreened. 


in others, at greater and more irregular intervals. In some vill^es 
the sanitary condition around the privies is extremely poor, wiiile 
in others some attempt is made to keep things relatively clean. 




SILER, garrison: THE EPIDEMIOLOGY OF PELLAGRA 265 


In the farming districts the methods of disposal fall in Classes 
E and F (Fig. 18). The open-surface privies on farms usually are 



Fia. IS. — Privy, Type E. Surface, unscreened. 








266 SILER, garrison: the epidemiology of pellagra 

poorly constructed and filthy, and the excreta are seldom removed, 
poultry being relied upon as scavengers. Negroes in the farming 



Fio. 17. — Privy. Typo E. Surface, unscreened. 







SILER, garrison: the epidemiology of pellagra 267 

districts seldom have privies, and we were greatly surprised to 
find that farmers of the better classes sometimes had no privies. 

The methods of disposal of excreta observed by us among the 
families of pellagrins in the different groups of the population are 
similar to the methods of disposal adopted by the general popu- 
lation in these groups. 

Many of the mill authorities are well aware of the importance 
of good sanitation, and it is their constant endeavor to improve 
conditions. Even now plans are under way for the installation 
of a water-carriage system of disposal in one or two of the larger 
and better mills. 

Summary. The average general sanitary index for all the privies 
studied is only 16, on a basis of 100 for perfect disposal. So far as 
population groups are concerned the methods of disposal in use by 
the general population are not different from those observed among 
pellagrous families. Between 30 and 40 cases of pellagra developed 
in the city of Spartanburg more or less away from mill districts, 
and only 8 of these cases used a water-carriage system of sewage 
disposal. In general the methods of disposal of excreta observed 
in this series are insanitary, and many of the diseases of the intestinal 
canal transferred by mechanical means, flies, etc., would find con- 
ditions most favorable for such transfer. 

D. Premises, The following table covers the observations made 
relative to the sanitary conditions of the premises of pellagrins: 


Location of House Relative to 

Air and soil: Dry 

Damp 

Drainage: Good 

Poor 

General cleanliness of premises; Good 

Fair . 

Poor 

Stagnant water: A’cs 

No 

Shade: None 

Little 

Much 

Undergrowth or shrubbery: None 
Little 
Much 

Barns: Number of houses hatdng barns 

Number of houses ha-ring no barns 

Animal;’* Dogs 

Cats 

Horses or mules 

Cows 

Goats .... 

■•..!!!! 

Rats 

Mice .... 


Moisture and Dampness. 

242 

6—248 

242 

6—248 

146 

90 

12—248 

7 

239—246 

145 

62 

38—245 

207 

36 

2—245 

90 

145—235 

76 

79 

54 

93 

6 

158 

88 

• 124 


“ Number of observations, 237. 



268 SILER, garrison: the epidemiology op pellagra 


SuxMMARY. In 98 per cent, of the cases the dwelling-houses were 
well located and the drainage w^as good. Stagnant water was 
noted on the premises in only 3 per cent, of the houses investigated 
(246). But few mosquitoes were observed. The entomological 
section of this report mil deal with permanent streams and collec- 
tions of water, with the blood-sucking insects breeding therein, 
and with other biting insects found in the houses, on the premises, 
dnd in the neighborhood. 

XVI. General Observations upon the Dietary. The data 
analyzed in this stud}?- are necessarily of a general nature, based on 
information obtained from statements of patients, physicians, 
storekeepers, millers, and others. 

In order to determine the relative frequency with which the more 
important foodstuffs were used, patients and their families were 
closely questioned as to how often certain articles of food would 
appear upon the family table, and with regard to the patient’s 
particular fondness for any particular dish. Replies to these ques- 
tions were recorded under the follomng heads; Dailj’', one or more 
times a day; habitually, one or more times a week, but not daily; 
rarely, at irregular intervals of more than a week; never. 

With a ^^ew to discovering any significant differences in the 
habitual dietary of the three groups in the population which show 
the greatest disparity in the prevalence of pellagra, the results of 
this inquiry are summarized for the rural population, urban popu- 
lation, and the mill-village population, separately. Thefee results 
are set forth in the follomng tables, which represent the actual 
number of pellagrins and the percentage of the total number of 
pellagrins from whom the particular information in question was 
obtained. 




Table XI. 









Habit- 



:SH Meats; 



Daily. 

ually. 

Rarely. 

Never. 


Mill popula- 

Number 

1 

51 

84 

11 


tion 

Per cent. 

1 

35 

57 

7 

Fresh beef in 

Urban popula- 

Number 

3 

27 

16 

0 

season 

tion 

Per cent. 

7 

59 

34 

0 


Rural popula- 

Number 

2 

20 

40 

12 


tion 

Per cent. 

3 

27 

54 

16 


fMiU popula- 

Number 

9 

68 

60 

10 


tion 

Per cent. 

6 

46 

41 

7 

Fresh pork in 

1 Urban popula- 

Number 

1 

33 

12 

0 

i 

season 

1 tion 

Per cent. 

2 

72 

26 

0 


Rural popula- 

Number 

4 

45 

18 

5 


[ tion 

Per cent. 

5 

63 

25 

7 


fMill popula- 

Number 

0 

32 

79 

34 


tion 

Per cent. 

0 

22 

55 

23 

Fresh fish in 

Urban popula- 

Number 

0 

14 

29 

2 

e 

season 

1 tion 

Per cent. 

0 

31 

64 

O 

oi 


! Rural popula- 

Number 

0 

7 

44 

on 


1 tion 

Per cent. 

0 

10 

61 




SILER, GARRISON: THE EPIDEMIOLOGY OF PELLAGRA 269 


Table XI.— Continued. 


Fuesh Meats: 

dill popula- 

Number 

Daily. 

1 

Habit- 

ually. 

59 

Rarely. 

81 

Never. 

6 


tion 

Per cent. 

1 

40 

55 

4 

Fresh fowl in J 1 

Jrban popula- 

Number 

1 

30 

14 

2 

• 

season 

1 

tion 

Per cent. 

2 

64 

30 

4 

Hural popula- 

Number 

2 

45 

23 

2 


tion 

Per cent. 

3 

62 

32 

3 

Coked Meats: 

'] 

Mill popula- 

Number 

1 

0 

25 

94 


tion 

Per cent. 

1 

0 

21 

78 

Cured beef 

Urban popula- 

Number 

0 

1 

10 

26 


tion 

Per cent. 

0 

3 

27 

70 


Rural popula- 

Number 

0 

1 

3 

66 


tion 

Per cent. 

0 

1 

4 

95 


Mill popula- 

Number 

92 

40 

10 

2 


tion 

Per cent. 

64 

28 

7 

1 

Cured pork 

Urban popula- 

Number 

25 

9 

9 

2 


tion 

Per cent. 

56 

20 

20 

4 


Rural popula- 

Number 

49 

12 

8 

1 

i. 

tion 

Per cent. 

70 

17 

12 

1 


Mill popula- 

Number 

1 

6 

45 

95 


tion 

Per cent. 

1 

4 

31 

64 

Cured fish 

Urban popula- 

Number 

1 

5 

15 

22 


tion 

Per cent. 

2 

12 

35 

51 


Rural popula- 

Number 

1 

3 

14 

53 


^ tion 

Per cent. 

1 

4 

20 

75 


Mill popula- 

Number 

0 

14 

80 

51 


tion 

Per cent. 

0 

10 

55 

35 

Canned beef 

Urban popula- 

Number 

0 

3 

20 

20 


tion 

Per cent. 

0 

7 

47 

46 


Rural popula- 

Number 

0 

2 

25 

46 

1 

^ tion 

Per cent. 

0 

3 

34 

63 


Mill popula- 

Number 

0 

7 

39 

88 


tion 

Per cent. 

0 

5 

29 

66 

Canned pork 

Urban popula- 

Number 

0 

2 

14 

24 


tion 

Per cent. 

0 

5 

35 

60 


Rural popula- 

Number 

0 

1 

7 

58 


tion 

Per cent. 

0 

2 

11 

87 


Mill popula- 

Number 

0 

20 

90 

30 


tion 

Per cent. 

0 

14 

64 

22 

Canned fish 

Urban popula- 

Number 

1 

7 

28 

8 


tion 

Per cent. 

2 

16 

64 

18 


Rural popula- 

Number 

0 

5 

38 

29 


, tion 

Per cent. 

0 

7 

53 

40 

Eggs, Buttek, and 

Milk: 

Mill popula- 

Number 

10 

36 

13 

2 


tion 

Per cent. 

16 

59 

22 

3 

Eggs 

Urban popula- 

Number 

7 

8 

0 

0 


tion 

Per cent. 

47 

53 

0 

0 


Rural popula- 

Number 

11 

12 

17 

3 


tion 

Per cent. 

25 

28 

40 

7 


Mill popula- 

Number 

114 

16 

12 

4 


tion 

Per cent. 

78 

11 

8 

3 

Butter 

Urban popula- 

Number 

33 

6 

8 

• 0 


tion 

Per cent. 

70 

13 

17 

0 


Rural popula- 

. Number 

51 

8 

9 

6 


tion 

Per cent. 

69 

11 

12 

8 


iMill popula- 

Number 

83 

21 

29 

12 


tion 

Per cent. 

57 

15 

20 

8 

, Milk 

^ Urban popula- 

Number 

16 

14 

10 

9 


tion 

Per cent. 

29 

25 

29 

17 


Rural popula- 

Number 

41 

IS 

18 

9 


. tion 

Per cent. 

49 

18 

22 

11 



270 SILER, GARRISON: THE EPIDEMIOLOGY 

OF PELLAGRA 


Table XI. — Continued. 







Habit- 



Vegetables, Flour, Lard: 


Daily. ually. 

Rarely. 

Never. 

Mill popula- 

Number 

120 

21 

3 

3 

tion 

Per cent. 

82 

14 

2 

2 

Fresh vegetables Urban popnla- 

Number 

36 

6 

4 

0 

in season tion 

Per cent. 

78 

13 

9 

0 

Rural popula- 

Number 

61 

11 

1 

0 

tion 

Per cent. 

84 

15 

1 

0 

Mill popula- 

Number 

4 

41 

70 

29 

tion 

Per cent. 

3 

28 

49 

20 

Canned vegetables Urban popula- 

Number 

2 

17 

25 

2 

tion 

Per cent. 

4 

37 

54 

5 

Rural popula- 

Number 

3 

8 

25 

37 

tion 

Per cent. 

4 

11 

34 

51 

Mill popula- 

Number 

142 

1 

: 0 

■ 0 

tion 

Per cent. 

99 

1 

0 

0 

Wheat flour ^ Urban popul.a- 

Number 

45 

0 

0 

0 

tion 

Per cent. 

10 

0 

0 

0 

Rural popula- 

Number 

71 

1 

0 

0 

tion 

Per cent. 

99 

1 

0 

0 

Mill popula- 

Number 

30 

16 

2 

0 

tion 

Per cent. 

62 

34 

4 

0 

Leaf lard Urban popula- 

Number 

10 

2 

. 0 

0 

(pork) tion 

Per cent. 

83 

17 

0 

0 

Rural popula- 

Number 

28 

4 

0 

0 

tion 

Per cent. 

87 

13 

0 

0 

Alill popula- 

Number 

101 

2 

23 

5 

tion 

Per cent. 

77 

2 

18 

3 

Compound lard Urban popula- 

Number 

37 

5 

2 

1 

tion 

Per cent. 

82 

11 

5 

2 

Rural popula- 

Number 

62 

1 

7 

1 

tion 

Per cent. 

87 

1 

10 

2 

Table XII. 





Corn Products. Corn Meal Used. 




Daily. Habitually. 

Rarely. 

Never. 


Mill population Number 

85 

21 

40 

0 


Per cent. 

58 

14 

28 

0 


Urban population Number 

23 

12 

10 

2 


Per cent. 

49 

26 

21 

4 


Rural population Number 

47 

13 

11 

0 


Per cent.. 

66 

18 

16 

0 


Source of Supply of Meal. Shipped Meal Ground in Nearby State 


Exclusively. 

Mostly. 

Rarely. 

Never. 


Mill population Number 

84 

8 

22 

4 


Per cent. 

71 

7 

19 

3 


Urban population Number 

29 

2 

5 

1 


Per cent. 

78 

5 

14 

3 


Rural population Number 

16 

9 

13 

4 


Per cent. 

38 

21 

31 

10 


Local Corn Ground Locally. 





Exclusively. 

Mostly. 

Rarely. 

Never. 


' Mill population Number 

30 

22 

2 

0 


Per cent. 

56 

40 

4 

0 


Urban population Number 

7 

7 

0 

0 


Per cent. 

50 

50 

0 

0 


Rural population Number 

32 

19 

4 

0 


Per cent. 

58 

35 

7 

u 




SILER, garrison: the epidemiology of pellagra 271 
Table XII. — Continued. 


Qttautt of Meal. 


Mill population 
Urban population 
Rural population 

Good. Musty, 

Number 41 49 

Number 13 12 

Number 34 18 

Use of Hominy of Grits. 

Daily. Habitually. 

Rarely. 

Never. 

Mill population 

Number 

9 

47 

53 

19 

Per cent. 

7 

37 . 

41 

15 

Urban population 

Number 

9 

16 

7 

5 

Per cent. 

24 

43 

19 

14 

Rural population 

Number 

5 

14 

23 

11 

Per cent. 

10 

Syrup. 

26 43 

Corn-starch. Whisky. 

21 

Mill population 

Number 
Per cent. 

47 

5 

19 


Urban population 

Number 
Per cent. 

23 

5 

9 


Rural population 

Number 
Per cent. 

27 

3 

6 



Meats. The following meats were used to a greater or less 
extent in these three subdivisions of the population: fresh meat, 
fresh pork in season, fresh fish in season, fresh fowl, dried or chipped 
beef, bacon, cured fish, canned beef, canned sausages, and canned 
salmon. Fresh beef is not a staple article of diet of any of these 
population groups during the summer months. By far the greater 
number of individuals among the mill-village and rural population 
groups used it but rarely, and some never, while the urban group 
used it more extensively. The actual percentages of those eating 
fresh meat, either rarely or never, are as follows: Rural cases, 
70 per cent.; mill- village cases, 64 per cent.; urban cases, 34 per 
cent. Fresh pork in season was used approximately equally in the 
three groups, but rather more generally in the rural group, the 
actual percentages of those using it daily or habitually being as 
follows: 

Urban cases, 74 per cent.; rural cases, 68 per cent.; mill-village 
cases, 52 per cent. 

Fresh fish is not a common article of diet in Spartanburg County, 
and was but rarely used in any of the three groups. This statement 
applies more particularly to the mill-village and rural population. 
The percentages of those using fresh fish either rarely or never 
are as follows: urban cases, 59 per cent.; rural cases, 90 per cent.; 
mill-village cases, 78 per cent. 

Fresh fowl was used quite extensively in all three groups par- 
ticularly during the summer months; most extensively by tlie rural 



272 SILER, GA.RRISON: THE EPIDEMIOLOGY OF PELLAGRA 

cases; less so by the urban group, and least extensively by the 
mill-village group. The actual percentages of those using fowl, 
either daily or habitually, are as follows: urban cases, 66 per 
cent; rural cases, 65 per cent.; mill- village cases, 41 per cent. 

Cured beef is used but rarely in any of the three groups. In 
95 per cent, of the rural group, 78 per cent, of the mill-village group, 
and in 70 per cent, of the urban group it was never used. 

Bacon (cured pork) is a common article of diet in all groups, 
being used either daily or habitually by 92 per cent, of the mill- 
village group, 87 per cent, of the rural group, and 76 per cent, of 
the urban group. 

Cured fish is little used in any of the three groups, though some- 
what more frequently in the city population than by the the other 
two classes. 

Canned beef is not used extensiveljL In 63 per cent, of the rural 
cases, 46 per cent, of the urban cases, and 35 per cent, of the mill- 
village cases it is never used. When used it appears to be eaten 
neither daily nor habitually. 

Canned sausages (pork) are quite extensively used although 
seldom with any great frequency or regularity. The farming popu- 
lation uses them least. 

Canned Fish. Canned salmon, while quite generally used, is 
not a staple article of diet in any of the groups. In 93 per cent, 
of the rural cases, 86 per cent, of the mill-village cases, and 82 per 
cent, of the urban cases it is rarely or never used. 

Eggs, Butter, and Milk. These farm and dairy products are used 
wdth great frequency and regularity in all three groups of the 
population. Eggs were used either daily or habitually by 100 per 
cent, of the urban cases, 75 per cent, of the mill-village cases, and 
53 per cent, of the rural cases. Butter was used daily or habitually 
by 89 per cent, of the mill-village cases, 83 per cent, of the urban 
cases, and 80 per cent, of the rural cases. Milk was used either 
daily or habitually by 72 per cent, of the mill-village cases, 67 
per cent, of the rural cases, and 54 per cent, of the urban, cases. 
The use of eggs and butter is not so common in the rural group as 
in the other two. It must be remembered, however, that a greater 
number of negroes are included in this group, and their diet is 
probably below that of the whites, more particularly from the 
standpoint of variety. For example. Table XI shows that in 3 
cases among the rural population, eggs were never used; 2 of these 
cases were negroes. Of 6 cases that never used milk, 3 were negroes. 
Our data are not sufficiently extensive to draw a careful comparison 
between the average dietary of whites and negroes at the present 
time. Further information on this subject will be sought the 
coming season. 

Vegetables. Fresh vegetables were used in season, to a very large 
extent, by all the groups. They were used either daily or habitually 



SILER; GARRISON: THE EPIDEMIOLOGY OF PELLAGRA 273 

by 99 per cent, of the rural cases, by 96 per cent, of the mill-village 
cases, and by 91 per cent, of the urban cases. Among the vegetables 
most commonly used may be mentioned cabbages, green corn, beans, 
potatoes (Irish and sweet), peas, tomatoes, and squash. During 
the winter months the available vegetables were confined largely 
to Irish potatoes, cabbage, peas, and beans. Canned vegetables 
were seldom used habitually. In 85 per cent, of the rural cases, 
69 per cent, of the mill-village cases, and 59 per cent, of the urban 
cases they were either rarely or never used. 

The lards used consisted of pure leaf lard, the compound lards, and 
pure vegetable (cotton-seed) lards. In 7 cases pure leaf (hog) lard 
was used exclusively. In many instances, particularly so in the 
rural cases, sufiicient lard was rendered from the pork killed at 
home to supply all needs for from two to eight months of the year 
or longer. Others used compound or pure vegetable lards exclu- 
sively. Inquiry among 50 non-pellagrous families in one mill- 
village showed the use of compound lards to be quite as extensive 
as among pellagrins. 

Some of the grocers catering to the well-to-do classes of the 
population in Spartanburg informed us that some customers 
preferred the pure leaf lard, while others preferred and used con- 
stantly the pure vegetable lards. 

Wheat Flour. Bread made of wheat flour was used daily by 
99 per cent, of the cases in each group, and was used habitually by 
the remaining 1 per cent. 

Coni Products. Among the corn products used are included 
corn meal, hominy, grits, syrup, corn-starch, and whisky. Corn- 
meal is a staple article of diet in all classes of the population in 
the area studied. In this series, 84 per cent, of the rural cases, 
75 per cent, of the urban cases, and 72 per cent, of the mill-village 
cases used corn-meal either daily or habitually. Two cases had 
not used corn-meal for a period of two years prior to the develop- 
ment of pellagra. These cases were two children whose mother 
had contracted pellagra in 1910, at which time she was advised 
by her physician to discontinue the use of corn products absolutely. 
She states that she had done so and that there had been no corn 
products in the house for the past two years. The children, aged 
six and thirteen years respectively, developed the disease in 1912. 

The meal was obtained from different sources. Many of the 
families used no meal other than that grown locally and ground 
at a local mill; others used such meal the greater part of the time; 
others^ used, exclusively, meal shipped in from a near-by state; 
and still other used such meal the greater part of the time, but used 
more or less meal made from local corn, locally ground. The 
cases in which both local and sliipped meal was used are included 
m both tables, which accounts for the apparent excess in numbers. 

Some families raised sufficient corn to supply them with meal. 



274 SILER, garrison: the epidemiology of pellagra 

locally ground, for from six to eleven months of the year, the 
renaainder being purchased from a grocer. The quality of the meal 
varied, 'l^dien meal was made from the home-raised corn it was 
the usual custom to grind it up in small amounts at frequent inter- 
vals, and such meal was said to be fresh and sweet. The meal 
purchased from grocers was sometimes musty, but such meal 
usually was fed to the chickens. The use of hominy and grits was 
not so common in these groups as had been expected. Among 
the rural cases 64 per cent., the mill-villages cases 56 per cent., 
and the urban cases 33 per cent, rarely or never used either. 

Comparative dietary studies on the normal non-pellagrous popu- 
lation under like conditions are desirable in any attempt to deter- 
mine the possible influence of the dietary on the development of 
pellagra. We have made some comparative, studies with this 
object in view, but our data are not sufliciently complete at this 
time to warrant any definite conclusions. 

The diet to which most of these cases were accustomed is of 
fairly good variety, but it is probable that in many instances the 
methods of preparation and cooking of the food are subject to 
criticism. Tliis matter lilcewise is to be made a subject of further 
investigation. We are quite certain, from personal observation, 
that the average dietary of the poorer classes of the population in 
the county studied is much superior both in its variety and actual 
nutritive value to the dietary of the peasants in the North of 
Italy. Another striking difference may be mentioned, namely, 
that corn-meal in the form of polenta constitutes the chief bread 
component of the diet of the peasant of Northern Italy, whereas 
in Spartanburg Countj^, among all classes of the population, wheat 
flour, in the form of bread or biscuit, is the principal bread-stuff, 
and corn-meal, while extensively used, is not nearly so staple an 
element of the dietary as wheat flour. 

X\^II. Synopsis. The epidemiological study of pellagra as it 
exists in Spartanburg County, South Carolina, is still in progress 
and will be continued during the spring and summer of 1913. _ The 
work done in 1912 constituted a more or less general preliminary 
survey of the field, and the results of that work as set forth in this 
report are tentative and ■vsdll be further tested by continued obser- 
vations and study. 

The results of the work in 1912 tend to strengthen the belief 
that a satisfactory’' knowledge of the epidemiolo^ of pellagra is 
best to be gained by intensive studies, of the behavior of the disease 
in selected communities, and of the prevailing conditions ivhich 
influence its local prevalence and distribution. It is hoped that a 
study conducted vdth sufficient care and thoroughness along th^se 
lines will yield valuable e^^dence either for or against the possible 
infectious nature of the disease and its possible communicability. 



SILER, garrison: the epidemiology of pelaagra 275 

The epidemiological data presented in the present report are 

summarized below: ... . • m • 

Part I. 1. Pellagra shows a strildng inequality of distribution 
in the ten townships within the county, the township rate of pre- 
valence per 10,000 of population varying from 0 to 71. The city 
of Spartanburg, with a population of 17,517 gave a rate of 49 
per 10,000 against 34 per 10,000 for the remainder of the county. 

2. Density of population while showing a tendency to conform 
to the relative prevalence of the disease does not alone offer an 
explanation of the geographical inequalities of its distribution 
within the county. 

3. The cotton-mill-village population gives a rate of prevalence 
of 104 per 10,000 against 19 per 10,000 for the remainder of the 
county, and against 16 per 10,000 for the rural sections alone. _ 

4. The variations in the rates of prevalence in the ten townships 
are in a measure proportional to the presence or absence of a large 
mill-village population. Excluding the mill-village population, 
there is still a marked discrepancy between the townships in the 
rural population alone, ranging from 0 to 29 cases per 10,000 of 
population. The excessive prevalence among the farming classes 
is found in the townships which have a relatively large mill-village 
population. 

5. The white population of the county gives a prevalence of 
45 cases per 10,000; the negro population a prevalence of 9.5 per 
10,000. Excluding the mill-village population which is practically 
all white, the remaining white population still gives a rate of 
prevalence (25.2 per 10,000) over two and one-half times that among 
the negroes. 

6. The rate of prevalence per 10,000 for males in the county is 
17; for females, 50.5. White males give a rate of 22.95 per 10,000; 
white females, 87.5 per 10,000, negro males, 3.9 per 10,000; negro 
females, 14.9 per 10,000. 

7. The rate of prevalence among children under ten years of 
age and among adults aged forty-five years and older is practically 
equal in the two sexes. 

8. The rate of prevalence drops among males between the ages 
of nineteen and forty-five years, whereas for females there is a 
remarkable excess of prevalence between these ages. 

9. In both males and females there is a striking fall in prevalence 
between the ages of ten and twenty years. 

10. The most significant fact with regard to oceupation is the 
excessive prevalence of pellagra among women employed in house- 
work. 

II- The excessive prevalence of pellagra in the mill-village popu- 
lation is found largely among women and children at home during 
the day. Among actual mill-workers the rate of prevalence between 
the two sexes appears to be about equal. 



276 SILER, garrison: the epidemiology of pellagra 

12. One-half of the cases occurred singly in one family; about 
one-fourth occurred two in one family; the remaining fourth 
occurred in groups of three, four, or five in one family. The question 
of the possible relative importance of family relationslup and 
household association is still under investigation. 

13. Among cases occurring singly in families, the proportion of 
children of both sexes under ten years of age is low and that of 
adult females excessively high. Among cases occurring two or 
more in one family the proportion of young children is proportion- 
ately high, especially among males. 

Part II. 14. While apparently authentic sporadic cases of 
pellagra within the county can be traced back to as early as 1894, 
the disease does not appear to have occurred in any great number 
of cases in any year until 1908. Since 1908 the incidence-rate 
appears to have rapidly increased each year to 1911. The number 
of new cases developing in 1911 appears to have been slightly 
greater than in 1912. 

15. There was no evidence pointing to any spring and fall 
recrudescence of the disease in the population so frequently re- 
ferred to in the literature of pellagra. There is no particularly 
marked tendency for the seasonal recurrence to appear in an indi- 
vidual during the same month, year after year. 

16. Influence of Climate. Climatic conditions appear to influence 
the development of symptoms of the disease. If during the spring 
months precipitation is high, temperature low, and number of 
rainy days excessive, the appearance of acute symptoms, more 
particularly those involving the skin, is delayed. 

17. Symptovwtology. It would appear that three or four years 
ago a large proportion of the cases observed in the county presented 
intestinal and nervous symptoms of great severity. In 1912, in 
many instances, symptoms were quite mild, and sometimes were 
confined almost exclusively to the cutaneous system, the disease 
appearing to be of a less virulent type in 1912 than in previous 
years. 

18. Economic Status. In the majortiy of cases (83 per cent.) 
economic conditions are poor and the disease is most prevalent 
among people of insuflBcient means. 

19. Predisposing Diseases. General health conditions in child- 
hood do not appear to warrant consideration as etiological factors 
when the disease develops in adult life. In a number of cases the 
development of pellagrous symptoms in children was preceded 
by one of the acute exanthematous diseases of childhood. About 
one-fourth of the cases gave a history of a preceding chrome disease 
in adult life. In more than one-half of the cases (62 per cent.) 
the history was that of good health. Aonong adult females, those 
most affected were married women (86 per cent.), and 86 per cent, 
of the married women had borne children. 



SILER, glerison: the epidemiology of pellagra 277 

A history of illness immediately preceding the development of 
pellagra was elicited in 59 per cent, of the cases. 

20. Hygiene and Sanitation of Houses and Premises. The most 
unsanitary condition found in the county is the absence of properly 
constructed privies. Outside of a part of the city of Spartanburg 
which is supplied by a water-carriage sewage system, there is no 
effective provision in the county for the proper disposal of human 
excreta. A second striking unsanitary condition is the almost 
complete absence of effective screening of dwellings. 

These two conditions present a situation highly favorable to the 
transmission of disease organisms eliminated in the excreta, both 
by direct contamination of food and person and by insects. This 
situation is naturally aggravated in the mill-villages and small 
towns by the greater congestion of houses. The absence of effective 
screening for dwellings gives rise to conditions conducive to the 
possible transfer of diseases transmitted by biting insects. 

21. Dietary. Observations upon the habitual use of the more 
common foodstuffs failed to discover any points of difference be- 
tween pellagrins and non-pellagrins in the county or any facts 
which would seem to explain the strikingly greater prevalence of 
pellagra among certain classes of the population. 

The most striking defect in the general dietary of the working 
classes, appears to be the limited use of fresh meats, the animal 
proteid being supplied largely in the form of cured meats, of which 
salt pork (especially bacon) is the most important. 

Unhygienic preparation of food appears to be a probable impor- 
tant factor in the general health of the population. 

Investigation of the kind, quantity, and qualtiy of corn and corn 
products used in the county failed to bring to light any epidemi- 
ological evidence pointing to the agency of corn as an etiological 
factor in the disease. The presence of two cases in our series giving 
a definite history of no corn consumption within two years prior 
to the onset of symptoms, together with several other cases in which 
corn products were eaten, if at all, only in small quantity and at 
extremely rare intervals, would seem to argue strongly against 
any hypothesis that corn products alone are the causative agent 
of the disease. 



REVIEWS 


Manual of CnEmsTRY. A Guide to Lectujies and Laboratory 
Work for Beginners in Chemistry. A Text-work Specially 
Adapted for Students of Medicine, Pharmacy, and Dentis- 
try. By W. Simon, Ph.D., M.D., Professor of Chemistry in 
the College of Physicians and Surgeons of Baltimore and in 
the Baltimore College of Dental Surgery; Emeritus Professor 
in the Maryland College of Pharmacy, Department of the 
University of Maryland, and Daniel Bare, Ph.D., Professor of 
Chemistry in the Maryland College of Pharmacy, Department 
of the University of Maryland, and of Analytical Chemistry in 
the Department of Medicine, University of Maryland, Balti- 
more. Tenth edition, thoroughly revised, with 82 illustrations, 
1 colored spectra plate and 8 colored plates representing 64 
chemical reactions. Philadelphia: Lea & Febiger. 

The many editions through which Simon’s Manual of Chemistry 
has passed, render somewhat superfluous on the reviewer’s part 
more comment than is necessary to point out where the present 
edition differs from its predecessors. There may be honest difference 
of opinion as to the wisdom of attempting to compass within one 
volume, the subjects of Physical Chemistry, Inorganic Chemistry, 
Analytical Chemistry, Organic Chemistry, and Physiological 
Chemistry, but this difference evidently does not extend to those 
for whom the book is primarily intended. Ten editions of any 
work indicate its popularity with its chosen audience. 

The authors have preserved in this the plan and characteristics 
of previous issues but have made many additions to the text, 
embracing such topics as exothermic and endothermic reactions; 
the theory of electrolytic dissociation and ionization, on which 
are based our present conceptions of the reactions of the body 
fluids; reversible reaction and chemical equilibrium; the chemistry 
of atoxyl, salvarsan, fiuorescin, phenolsulphonephthalein, etc. In 
their own words the aim of the authors has been “to furnish the 
student in concise form a clear presentation of the science, an 
intelligent discussion of those substances which are of interest 
to him and a trustworthy guide to his work in the laboratory. 
In this they may fairly be said to have succeeded and many 
readers whose equipment in chemistry is rusty or has never 



keen: surgery, its principles and practice 279 

included the modern advances, will find iiere a simple and clear, 
if not complete, exposition of the subjeet. 

The type is large and the wood euts fulfil their purpose as 

illustrations. 


Surgery, its Principles and Practice, by Various Authors. 

Edited by William Williams Keen, M.D., LL.D., Emeritus 

Professor of the Principles of Surgery and of Clinical Surgery, 

Jefferson Medical College, Philadelphia. Volume VI; pp. 1177; 

519 illustrations. Philadelphia and London: W. B. Saunders 

Company, 1913. 

This is a supplementary volume, designed to bring up to date 
the various chapters contained in the original five volumes of the 
work, which were published between 1906 and 1909. There are 
very few topics to which no additions have been made, owing to 
the rapid advance in surgical practice; and some entirely new 
subjects have presented themselves for discussion. Among the 
more important of the latter are Crile’s principle of anoci-associa- 
tion, the surgery'' of the hypophysis, and modern thoracic surgery. 

The most interesting additions to the principles of surgery are 
the explanation given by Adami of the value of poultices in favor- 
ing the pointing of an abscess, and his description of the use of 
cell proliferants, of Scharlach R., and of allantoin. In similar 
vein is Freeman’s discussion of the treatment of abscesses by fer- 
ments and antiferments. Such matters as these remind us that 
progress occurs in the science as well as in the art of surgery. 

T. Turner Thomas has prepared the supplementary chapter on 
surgical tuberculosis. He discusses the treatment with tuberculin, 
the uses of the formalin-glycerin solution, which should never be 
less (not more) than twenty-four hours old when used; and he 
makes brief but rather inadequate mention of tuberculous rheuma- 
tism. This, as well as the broader subject of inflammatory tuber- 
culosis, merits wider attention than it has heretofore received out- 
side of France. 

In the supplementary chapter on Orthopedic Surgery it is very 
surprising to find that Lovett dismisses the bone transplantation 
for Pott’s Disease (Albee) as a method still on trial, and that no 
mention whatever is made of one of the most revolutionary practices 
ever introduced into any department of surgery, namely, the 
Abbott treatment of scoliosis. 

Dean D. Lewis and Kanavel contribute a chapter of fifty pages 
on the surgery of the hypophysis. Its comprehensiveness may be 
indicated by the statement that much of it is in small print, and 
that the bibliography alone covers three pages. 



280 


EEVIEWS 


O^'-en supplements Iiis original article on the surgery of the 
neck by giving the technique of operations for malignant disease 
in this region; but he does not commit himself as to whether or 
not the operation, when it involves the mouth, should be completed 
in one or in two sittings. He quotes Braun's experiences in per- 
forming some of these most radical operations under anesthesia 
by infiltration of the branches of the trigeminal nerve with cocaine; 
but he concludes that while Braun’s essay is an attractive one, it 
is not altogether convincing to a surgeon like Owen himself who 
has a dread of the risks of cocain poisoning. 

Murphy, like everyone else, is theoretically awake to the advan- 
tages of the transverse incision in the lateral regions of the abdomi- 
nal wall. He mentions the contributions of both Hockey and 
Hesselgrave, but fails to credit J. W. Elliot, or G. G. Davis, or 
Chaput for their original work in this connection. And as appears 
by a recent number of Murphy’s Climes, Murphy himself adheres 
to the longitudinal incision which divides the motor nerves of the 
rectus muscle. Murphy pays particular attention in this supple- 
mentary chapter to the end-results of operations on the appendix, 
to the complications of appendicitis, and to intussusception, tuber- 
culosis, actinomycosis, and malignant tumors of the appendix. 

Dr. Hugh H. Young, in revising his chapter on the surgery of 
the prostate, lays special stress on the beneficial effects of prepara- 
tory treatment in reducing the postoperative mortality from 
renal complications, and claims unequalled value for the phenol- 
sulphonephthalein test. It is noticeable, also, that he spealcs with 
less contempt than formerly of the suprapubic operation. 

Military and naval surgery are ably discussed by Borden and 
by Bell respectively. Both dwell on the education which is neces- 
sary before the average surgeon in civil life can be developed into 
a medical oflScer sufficiently competent to take charge of military 
or naval affairs, or public hygiene; and Borden especially points 
out the many and increasing advantages, scientific and ma,terial, 
which are open to a young physician who elects to adopt a military 
career. 

New topics of absorbing interest, arthroplasty and transplanta- 
tion of bone, are ably discussed by Warbasse; while Bickham,-in 
his supplementary chapter on amputations gives admirable descrip- 
tions of methods of amputation for cinematic prosthesis. Unfortu- 
nately neither he nor Warbasse appear to speak from personal 
experience. . 

The volume closes with supplementary chapters on Plastic 
Surgery, by John B. Roberts; the Surgery of Accidents, by W. L. 
Estes; Surgery of the Infectious Diseases, by G. E. Armstrong, 
the X-rays in Surgery, by Codman; and includes moreover ^ 
cussion of various modern developments of the anesthetic problem, 
such as Anesthesia in differential pressure chambers, by Wuly 



eoemer; text— book of ophthalmology 


281 


Meyer; Anesthesia by Intratracheal Insufflation, by S. J. Meltzer; 
Intravenous Ether Anesthesia, by Kununel; and Spinal Anesthesia, 

by Houghton. „ . , i j 

A complete index to the entire series of six volumes concludes 

this valuable and well nigh indispensable work. A. P. C. A. 


Text-book of Ophthalmology in the Fokm of Clinical Lec- 
tures. By Dr. Paul Roemer, Professor of Ophthalmology 
at Greifswald; Translated by Dr. Matthias Lanckton Foster, 
Member of the American Ophthalmological Society, etc. Volume 
II, pp. 294, 186 illustrations and 13 colored plates; Volume III, 
pp. 323, 186 illustrations and 13 colored plates. New York: 
Rebman Company. 

These are the concluding volumes of this text book of ophthal- 
mology. Volume II contains the chapters upon diseases of the 
lids, vitreous, sclera, lacrymal organs, and orbit, with chapters 
upon injuries, glaucoma, and concomitant strabismus. In volume 
III the affections of the chorioid, retina, and optic nerves, with 
chapters upon the pupil, pareses of ocular muscles, neurology and 
functional testing are taken up. An appendix by the translator 
with a complete index and list of authors concludes the work. 

Common sense views pervade the whole, No fads are exploited. 
The semeiology is presented largely in the form of clinical histories. 

As examples of the author’s treatment of certain interesting 
portions of ophthalmology we may select the following as illus- 
trations. Diseases of the orbit are very fully described; the various 
forms of orbital cellulitis are well set forth, particularly the part 
played in the etiology and symptoms by disease of the accessory 
sinuses of the nose. The differential diagnosis from affections of 
each of these sinuses is well presented. They are held to be re- 
sponsible for more than 60 per cent, of all cases of inflammatory 
exophthalmos, hence the invariable rule to examine the accessory 
sinuses in every case of disease in the orbit — a rule which vnW lead 
to the saving of many eyes and the preservation of many lives. 
But while the nasal origin is thus fully insisted upon, the author 
takes the ground properly, that the treatment of the underlying 
sinusitis should be left to the rhinologist, though orbital abscesses 
must be freely evacuated in the interest of sight as well as of life. 
Extirpation of the lacrymal sac is declared to be the treatment of 
chronic catarrhal dacryocystitis. Probing is condemned; Toti’s 
operation is not mentioned. The diseases of the lacrymal passages, 
epiphora, stricture, acute, and chronic inflammations of the sac 
are regarded only as individual links in a clmin of diseases in which 

VOL. 1-(G, NO. 2. — .VUGOST, 1913 10 



282 


REVIEWS 


the general practitioner by proper and timely treatment can take 
an active part. 

Of sympathetic ophthalmia, which is still an interesting and 
important mystery in_ ocular pathology, an excellent summary of 
the views held by leading experimenters is given. There are (1) the 
migration hypothesis of Leber and Deutschmann; (2) the modified 
cilioneural hypothesis of Schmidt-Rimpler, and (3) the metastasis 
view of Berlin and the author. The first assumes the migration 
of a virulent agent, staphylococcus or other, from the first to the 
second eye by way of the optic nerve — a view which does not 
appear consistent with all the phenomena of the disease. Schmidt- 
Rimpler’s hypothesis that irritation of the ciliarj^ nerves in the 
eye first affected induces a susceptibility in the other through a 
reflex disturbance, is likewise rejected. Tanas’ addition to this ob- 
scure conception that general toxic influences, such as alcoholism, 
catarrhal disease of the nose and throat, ete., are predisposing 
factors, is not regarded as adding strength to the hypothesis. From 
all the known facts, the author concludes that the only hypothesis 
yet presented which is also consistent with experiment, is that 
sympathetic irido-cylitis originates hematogenously just the same 
as spontaneous irido-cyclitis, and is due to a specific metastasis 
from the eye first diseased by an agent yet unknown, which is 
dangerous to the eye only and not to the other organs. It is ob- 
vious that prophylactic treatment will be largely influenced by 
the surgeon’s view as to the pathogeny of the affection. 

After detailing the changes usually found in persistent glaucoma 
and tracing the clinical symptoms to the hypertension, the state- 
ment is made that the origin of the latter has not yet been explained, 
although gain is derived from the knowledge acquired in regard 
to treatment. Of the three cardinal symptoms in the glaucomatous 
eye, the changes in the bloodvessels, the cupping of the disk, and 
the alterations in the filtration angle, the latter alone is amenable 
to treatment, in that miotics or operations shall free this angle. 
Of iridectomy the author believes that he states the conviction 
of soberly thinking ophthalmologists, that while the operation 
delays the glaucomatous process, it does not permanently cure it; 
indeed, he advises that miotics should always be tried first whatever 
the form of disease present. The newer operations such as cyclodi- 
alysis and sclerectomy are fairly presented. The origin and outlet 
of the intra-ocular fluids with the effect of the same and other in- 
fluences upon the intra-ocular tension are quite fully considere 
as bearing upon the pathology of glaucoma. 

The chapter upon the neurology of the eye gives a goao. resume 
of the value of ocular symptoms in the diagnosis and localization 
of disease of the nervous system — so important in certain conditions 

and valueless in others. ^ c 

In an appendix, the translator. Dr. Foster, gives an accoun o 



hakt: guide to midwifery 


283 


asthenopia, particularlj" as developed in this country and some of 
the special methods of measuring the refraction, and also the im- 
balance of the extrinsic muscles, ivith some hints as to the appro- 
priate treatment. Asthenopia of nervous origin and the form 
dependent upon reflex causes are briefly considered. 

The work as a whole may be described as a satisfactory exposition 
of modern ophthalmology. It is perhaps not so well adapted for 
beginners as certain more elementary text-books and contains 
nothing strildngly novel; it sets forth modern conceptions clearly 
for the reader who comes prepared with some previous acquaintance 
noth the subject. 

We take pleasure in repeating here what we have said in our 
review of the first volume, viz., that Dr. Foster has been most 
successful in giving the work an English dress. It reads almost as 
if it had been originally written in English and this is high praise 
for any translation. He is also to be congratulated in having per- 
mitted the original German author to expound his own views 
without doing them to death by constant interpolation of the 
translator. The book is an expensive one, and this counts in these 
days when almost every teacher in every medical school, the world 
over, considers it his bounden duty to put forth in some form, an 
exposition of his own upon the subject in which he is interested. 

T. B. S. 


Guide to Midwifery. By David Berry Hart, M.D., F.R.C.P.E., 
Lecturer on hlidwifery, School of the Royal Colleges, Edinburgh. 
Pp. 765, with 4 illustrations in color and 268 diagrams. New 
York: Rebman Company. 

Hart presents his Guide to Midwifenj in two parts. The first 
and larger section is devoted to a clear and full exposition of the 
necessary facts of obstetrics from a modern standpoint. To each 
chapter is appended a scheme for the practical instruction of the 
student. References are made to the various atlases, models or 
specimens to be examined in connection with the text. References 
are also given to corresponding sections of the second part. 

The author states in the preface his belief that a text-book on 
midwifery should not be copiously illustrated, but that one should 
obtain his ideas of the subject from the knowledge gained by the 
actual handling of specimens. The illustrations are with a few 
exceptions, well executed and include several excellent colored 
plate.s. j\Ian 3 ' reproductions of frozen sections are shown to illus- 
trate the steps in the mechanism of labor, and the pathological 
conditions of the parturient canal. 

11 liile gi^ ing an otheru'ise good system for the examination and 



284 


REVIEWS 


care of the pregnant woman, in the chapter on hygiene of preg- 
nancy, no mention is made of antepartum pelvimetry or of routine 
estimation of the blood pressure. 

A thorough discussion of eclampsia is given at the expense of 
only brief notes on the less severe forms of the toxemias of preg- 
nancy. The repeated statement that chloroform may be given 
with entire safety to the pregnant woman, especially in the treat- 
ment of eclampsia, may be subject to question in the light of recent 
investigations. 

Proper emphasis is placed on the importance of breast feeding 
in a well written section on the infant. Among the pathological 
conditions of the infant no mention is made of hemorrhagic disease 
or of its successful serum therapy. 

The various obstetrical operations are described in detaill The 
classical Cesarean section being favored by the author in the 
treatment of labor in contracted pelves rather than the girdle 
splitting operations or the lately revived extraperitoneal Cesarean 
section. 

The second part of the book entitled “Notes and Discussions” 
takes up in an order corresponding to the first part the various 
theories, old and modern concerning disputed points. New oper- 
ations are described and comparative statistics are included. In 
the chapter on evolution of obstetrics is found a discussion of 
Darwinism, Mendelism, and Weissmanism and their relation to 
this branch of medicine. A short section sums up the more recent 
views of the relations of the organs of internal secretion to the 
reproductive period. 

The literature is given in a separate section under specific head- 
ings and a comprehensive index is added. There is much to be 
recommended in the book, especially the method of arrangement. 

P. F. W. 


The Surgery of the Stomach. A Handbook of Diagnosis and 
Treatsient. By Herbert J. Paterson. Pp. 304; 74 illustra- 
tions. New York: William Wood & Company, 1913. 

We have in this volume a consideration of a field of surgery which, 
in its scope and usefulness, is growing rapidly. It is covered fully 
but not with burdensome detail. The methods of examination 
and the operations described, and the opinions expressed, are almost 
entirely those employed by the writer. Little space is given to 
the work of others in this field, except to that of W. L Mayo who 
is freely quoted and to w^hom the book is dedicated. The firs 
chapter of sixteen pages is devoted to the method of investigating 
gastric conditions, including those of the duodenum, and at t e 



hilger: hypnosis and suggestion 285 

end of the book is an appendk of fifteen pages in which is described 
the technique of the various methods of examining the gastric con- 
tents. The descriptions of operations and the illustrations are, in 
the main, excellent, although some of the views expressed are not 
in agreement with those commonly entertained. For instance,^ it 
is not generally agreed that it is immaterial whether the anterior 
or posterior gastrojejunostomy be performed. Nor is it in accord 
with general surgical practice in this country to sacrifice the ad- 
vantages of the Roosevelt or other three-jawed clamps in this 
operation. The description of gastrectomy is somewhat confused 
by the fact that the illustrations are those of W. J . Mayo, and the 
writer’s description does not tally with them, particularly with 
regard to the application, of the clamps. Nor does it seem proper 
to approve in a book of this kind, the recommendation of proprie- 
tary articles of food, one of which has been especially offensive in 
its method of advertising, and has been criticised by our represen- 
tative medical journals. These, however, are minor deficiencies and 
do not retract from the generally high standard of the work, which 
will undoubtedly meet with an appreciative reception from those 
who need books of this land. At the end of each of the more 
important chapters is a valuable summary of the important facts 
in the chapter, which will aid the reader in carrying the facts to the 
bedside and operating table, T. T. T. 


Hypnosis and Suggestion. By W. Hilger, M.D,, of Magdeburg, 

Translated by R. W. Felkin, M.D., F.R.S.E. Pp. 233. New 

York: Rebman Company. 

The introduction to this book is a practical summary of what 
follows, it being written by Dr. Van Renterghem, Judging from 
it and from the contents of the volume itself, it is principally a 
defense and ex-position of the fact that Liebeault of the University 
of Nancey was the originator of modern hjqmotism and its treat- 
ment. It then gives a history of this master, his methods and the 
theories upon which hypnotism are based. According to him 
healthy persons are most suitable for hypnotic treatment, whereas 
Charcot and those who followed him claim that hypnosis could 
be induced only in those suffering from nervousness, especially 
hj steria, and that it was a dangerous weapon, useless for thera- 
peutics and only_ useful for experimental research. Following 
Liebeault, Beriilieim, Vogt, and Forel did excellent work in h 3 ’'p- 
nosis. There is a scathing criticism of Dejerine and Dubois, in 
nhich the former is accused of ha\dng made use of the writings of 
Liebeault without giving him credit, while of the latter, who ' 



286 


REVIEWS 


published his book in 1904, it is said that in reading this book 
everytHng that is worth while in suggestive therapeutics originated 
with him. On the contrary, great credit is given the new school of 
psj'cho-analysis as exemplified by its originator Breuer and its 
most famous exponent, Freud. 

The volume itself, wliile it is written for the laymen and the 
general practitioner, is nevertheless a very good exposition of 
hj^notism, its methods of application and the results to be obtained 
from it. Everyone of us know that there is a deep-rooted skepticism 
of the uses of hj’pnosis in the treatment of disease. This is largely 
because of the commercial uses made of it. That hj^notism is a 
legitimate and excellent method of treatment for some functional 
diseases, there is no question, for certainly such men as Vogt, 
Forel, and others who have been mentioned would not use it. 
The truth of the matter is that hypnotism should be employed, 
but carefully, and only in the hands of those who are thoroughly 
capable of appljdng it. Its indiscriminate use by poorly trained' 
indmduals should be strongly condemned. The author has 
apparently had good results, but even he makes claims which are 
somewhat difficult to believe. T. H. W. 


The Care of the Skin in Health. By W. Allan Jamieson, 
M.D., Consulting Physicians for Diseases of the Skin, Edinburgh 
Royal Infirmary. Pp. 109; 2 illustrations. London: Henry 
Freude, Hedder and Stoughton. 

The author divides the subject matter in his little volume into 
an easily understood description of the structure of the skin, the 
care of the skin, the care of the hair and the nails, and suggestions 
as to diet and clothing. The small work is evidently intended for 
the general public as the author has made the entire volume quite 
understandable to the lay comprehension. Particular stress is 
laid upon the batliing regulations, as to the temperature of the 
water, the composition of the soap, and frictional, exercises following 
the ablution. T. C. K. 


hlANISCH-DEPRESSHES HNU pERIODISCHES IrRESEIN ALS ERSCmi- 
NTJNGSFORM DER ICatatonie. Eine Monograph von Dr. Med. 
jMATJRYCY Urstein, Watschau. Pp. 650. Berlin und Vien: 
Urban und Schwarzenberg, and Rebman Co., N. Y. 

This monograph is the complement of the previous one written 
by the author upon Dementia Prcecox and its Relation to Marne- 



ADAMSON: GOULSTONIAN LECTUBES 


287 


degressive Insmvity. The present work is upon manic depressive 
and periodic insanity, and its relation to katatonia. The 
comes to the conclusion that these two types of insanity should 
not be considered as distinct, but are really states of katatonie. 
He bases his conclusion upon an analytical study of thirty cases. 
It is a splendid bit of work, and should be read by everyone who is 
interested in insanity because it exemplifies what can be accom- 
plished by profound analytical study, and is a distinct advance 
in modern ps.ychiatry. T. H. W. 


Goulstonian Lectukes, 1912; Modern Views upon the Sig- 
nificance OF Skin Eruptions. By H. G. Adamson, M.D., 

F.R.C.P. (Lond.), Physicians for Diseases of the Skin, St. 

Bartholomew’s Hospital. Pp. 103; 43 illustrations. London: 

John Bale, Sons & Danielsson. 

Although practically every other field of medicine has been 
covered in the Goulstonian lectures, a dermatologist has not 
delivered this series of talks since Dr. Liveing delivered his classical 
exposition upon leprosy. The little volume under review consists 
of the three lectures delivered by Dr. Adamson before this repre- 
sentative body. No more interesting subject could have been 
selected than the study of the significance of skin eruptions, as 
viewed from the most modern and advanced point of view. A 
considerable portion of the volume is devoted to local and general 
immunity in various diseases of the skin and to the interesting 
subject of anaphylaxis. The local reaction of the different layers 
of the skin, depending upon the irritating stimulus is plainly shown. 
The author takes the view, that in at least certain diseases, the 
eruption is a defensive reaction to the causative reagent; the type 
of the outbreak depending upon the character of the stimulus. 
The very interesting local and general immunity that is produced 
in certain deep-seated trichophyton and the cuti-reaction to cultures 
of the ringworm are among the most interesting details presented 
in the book. Among other phases of the subject touched upon 
are the relationship of immunity production to the treatment of 
skin diseases; the idea and the origin of toxins; the relationship 
of toxic bodies to er;^i;hematous, urticarial, and drug eruptions; the 
origin of eruptions resulting from toxins from a distant bacterial 
focus; auto-intoxication; the significance of the patterns and dis- 
tribution of s^n eruptions, as to the influence of local physical 
agents. The little volume cannot be too strongly recommended to 
all those interested in dermatology and modern views on the 
etiology of diseases of the skin. F. C. K. 



288 


REVIEWS 


Minor Surgery. By Leonard A. Bidwell, F.R.C.S., Senior 

Surgeon to West London Hospital, Dean of Post Graduate 
■ College, etc. Second edition; pp. 292; 129 illustrations. London: 

University Press, by Hodder & Stoughton, and Henry Froude. 

This work has gone to its second edition in twelve months, an 
argument in favor of its meeting the needs of the times. In every 
respect the changes in this edition are improvements over the first 
edition. The size of the volume, the binding, and the more exten- 
sive index are all advances. There has been added a chapter on 
bandaging and minor injuries which contain all that is necessary 
for a general practitioner to know. The work is not meant to be 
a completed treatise on any one of its subjects, but is meant to 
give simple and clear directions for the management of everyday 
surgical procedures. The attention to detail is worthy of note 
everywhere in the book with but few exceptions, and in many 
instances the author states facts of utmost importance, which have 
been experienced by him and yet are not mentioned - in more 
extensive works in surgery. 

The text is clear, concise, and to the point. There is no theoriz- 
ing and no statements made that are not proved facts. Symp- 
tomatology is not touched upon, the entire work being given to 
treatment. The book is an admirable one for students, nurses, 
internes, and general practitioners, but is rather too elementary 
for surgeons of any experience, which I believe is the claim made 
by the author. E. L. E. 


Studies in Psychiatry. By Members or the New York 
Psychiatrical Society. Pp. 222; 14 illustrations. New York; 
The Journal of Nervous and Mental Disease Publishing Co. 


As represented by the title this volume consists of reprints of 
fifteen papers written by various members of the New York 
Psychiatrical Society. It is diflicult to pick out a particular paper 
of this important group for review. Perhaps the most interesting 
is one by Dr. Frederick Peterson on “The Insane in Japan, am 
one on “The Curability of Early Paresis,” by Dr. Charles L. 

Dana. • n* l 

The papers here represented constitute the first of a senes 

are to be published by this Society. T. H. W. 



PEOGBESS 


OF 

MEDICAL SCIENCE 


MEDICINE 


T5NDBR THE CHARGE OF 

W. S. THAYER, M.D., 

PHOFESSOR OF CLINICAL MEDICINEi JOHN'S HOPKINS TTNIVEKSITVi BALTIMORE/ MABTLAND, 

ANt> 

ROGER S. MORRIS, M.D., 

CHIEF OF THE DEPARTMENT OP INTERNAL MEDICINE, CLIFTON SPRINGS SANATORIUM AND 
HOSPITAL, CLIFTON SPRINGS, NEW TORE. 


Primary Splenomegaly (Gaucher Type), — ^Mandelbaum (Jour. 
Exper. Med., New York, 1912, xvi, 797), after a review of the reported 
cases and study of a case of his own with autopsy, concludes that 
primary splenomegaly of the Gaucher type is a distinct disease, related 
in all probability to the blood diseases. It begins usually at an early 
age, frequently affects several members of a family, and runs a chronic 
course. The clinical manifestations are: Pronounced hypertrophy 
of the spleen; subsequent enlargement of the livCr; discoloration or 
pigmentation of the skin; tendency to epistaxis or other hemorrhages; 
absence of palpable lymph nodes; absence of jaundice and ascites, and 
absence of characteristic blood changes. The lesions are found in the 
spleen, Ijunph nodes, bone marrow, and liver. These organs show 
iron-containing pigment and large muitinuclear cells with a char- 
acteristic cytoplasm. In the early cases, peculiar large phagocytic 
cells arising from atjq)ical large lymphocytes are found in the follicles 
of the hemapoietic S5^stera. After leaving the follicles these cells possess 
phagocytic qualities for a certain period. As a result of the phago- 
cytosis the cells enlarge, the nature of the cytoplasm changes, and the 
cells acquire a characteristic vacuolated and wrinkled appearance. 
The cells are carried from the spleen through the portal system to the 
liver, where they are destroyed. The irritation produced by this 
destructive process gives rise to an increase in the intralobular con- 
nective tissue. Tile disease is eminently a chronic one, without any 
of the manifestations of malignancy, and always terminating as the 
result of some intercurrent affection. The etiology is unknovm, al- 
though a family predisposition to, some toxic agent which causes an 



290 


PROGRESS OF MEDICAL SCIENCE 


irritability of tbe follicles in the liemapoietic system probably exists. 
The possibility of some protozoan infection, as an etiological factor, 
must not be overlooked. 


Eenal Diabetes during Pregnancy— J. Novak, 0. Forges, and R. 
Strisower (Deuisch. med. Woch., 1912, xxxviii, 1868) have made a 
study of the spontaneous glycosuria of pregnancy. In 2 cases they 
found that the excretion of sugar Avas independent of the diet, "^hth 
the carbohydrates eliminated from the food, sugar Avas still excreted 
in the urine; but an abundant supply of carbohydrates in the diet 
did not lead to a corresponding increase of the sugar in the urine. 
Furthermore, they found that the glucose content of the blood Avas 
normal, cA^en subnormal. They Avere dealing, therefore, Avith a condi- 
tion Avhich has been described as renal diabetes, in AV'hich it is supposed 
that the kidney, as in phloridzin glycosuria, is abnormally permeable 
to sugar. The preAuously recorded eases haA’-e been unassociated Avith 
pregnancy. It Avas anticipated by the authors, then, that the occur- 
rence of renal diabetes in 2 consecutive pregnant Avomen AV'as more 
than a coincidence. They liaA^e been able to obserA’^e 5 other preg- 
nancies AAuth glycosuria, and in none of them A\'as there a hyperglycemia, 
in none Avas the quantity of glucose in the urine influenced to any 
considerable degree by variations in the quantity of carbohydrate 
consumed. In 2 of the patients A\'ho haA^e been deliA’-ered, the glyco- 
suria has ceased spontaneously. NoAmk, Forges, and StrisoAver are 
of the opinion that renal diabetes and pregnancy are not infrequently 
associated. 


Edema of the Lovrer Part of the Esophagus from Vomiting. — ^At the 
suggestion of Professor Schmorl, F. Rost {Dcutscli. med. Woch., 1912, 
xxxviii, 1694) has examined the esophagus in a large series of autopsies. 
This Avas done, because Schmorl had noticed a rather marked edema 
of the cardiac end of the esophagus in several cases of septic peritonitis. 
Rost’s study shoAved that edema is the rule in such cases. It affects 
the mucosa, the submucosa, and extends into the muscularis mucosre. 
The edema seldom extends more than 3 to 5 cm. above the cardiac 
end of the esophagus; in other Avords, it affects the intra-abdominal 
portion of the esophagus. In all cases A\Fere marked edema Avas found, 
Ammiting had been a prominent symptom. In other conditions Avith 
frequent Ammiting shortly before death, such as strangulation of the 
boAvel, cancer of the stomach, etc., edema v^as found only in about 
one-half of the cases; it Avas never very marked. Again, in cases of 
septic peritonitis in Avhich there had been little vomiting, edema AA^as 
usually slight. The author belicA'^es, therefore, that A'^omiting is an 
important factor in the production of edema of the loAA^er end of the 
esophagus, but that the toxins absorbed from a septic exudate also 
promote its development. 

Experimental Observations on the Influence of Venesections and 
Intraperitoneal Blood Injections on the Number and Resistance of 
Red Blood Corpuscles. — ^K. Oczesalski and St. Sterling {Deutscn. 
Arch. f. Min. Med., 1912, cix, 9) have tested the effect of AvithdraAV'al 
of blood and of intraperitoneal blood injections experimentally on 



MEDICINE 


291 


rabbits, in an attempt to discover whether the method might have 
value in the treatment of human anemias. They find : (1) Venesections, 
6 VCI 1 when large, if not repeated at too frequent intervals, not only 
produce no harm, but cause an increase in the resistance of the red 
blood cells. (2) Venesections in connection with injections of the 
same blood in the peritoneal cavity are harmless to the healthy animal 
and increase the resistance of its red blood corpuscles and also the 
total number of red cells. (3) Venesections in connection with injec- 
tions of the shed blood in anemic animals cause an increase of hemo- 
globin and total red count and of the resistance of the red blood cor- 
puscles. A similar procedure would seem to be justifiable in simple, 
chronic, post-hemorrhagic anemias, of course, with strict asepsis. 
(4) Injection of foreign blood following venesection produces the same 
results in anemic animals as described in (3). Clinically, this is less 
useful, as a donor must be found. (5) The same results follow the 
injection of foreign blood without venesection. 


On the Relation of Eosinophilia to Anaphylaxis. — Schlecht and 
G. ScHWENKER {DeutscL Arch.f. Iclin. Med., 1912, cviii, 405) summarize 
their experimental observations on the relation of eosinophilia to 
anaphylaxis as follows: Through continued parenteral administra- 
tion of foreign protein a peripheral blood eosinophilia may be pro- 
duced in the guinea-pig. With large doses a similar result may be 
obtained in dogs. Following recovery from anaphylactic shock an 
intense eosinophilia likewise occurs. Furthermore, the lungs of guinea- 
pigs which have withstood anaphylactic shock, exhibit a marked 
eosinophilic infiltration of the lung tissue and a peribronchial collec- 
tion of these cells. Similar changes may be produced in animals sensi- 
tized intraperitoneally, by inhalation of serum. The peribronchial 
and pneumonic infiltrations are markedly eosinophilic, in contrast 
to the pneumonias produced by inhalations of bacteria. In Arthus’ 
skin phenomenon the cells of the inflammatory swellings are chiefly 
eosinophiles. A local eosinophilia of the submucosa is seen in the 
intestine of dogs following anaphylactic enteritis. A local production 
of eosinophilous was not observed in these conditions. It is evident 
that the eosinophiles play a definite role in anaphylaxis. The authors 
are inclined to the view that certain products are formed in parenteral 
administration of protein which exert a positive chemotactic action 
upon the eosinophilic cells; they are attracted from the blood and 
bone-marrow, where they are present in increased numbers. Whether 
they are dealing with a single substance or several distinct bodies is 
unknown. 


Observations in Two Cases of Pentosuria.— Kj. Otto af Klebcker 
{Deutsch. Arch. f. klin. il/cd., 1912, cviii, 277) has made a careful study 
of the urine of 2 patients with pentosuria. It is of interest that the 
patients were brothers, that a third brother suftered with diabetes 
melhtus, and that the father of the three was a diabetic. Klercker 
found that the osazone obtained from the urine of each patient was 
dextrorotatory. By the degree of rotation found, it is practically 
certain that the pentose m one of the cases was l-arabinose, while in 
the other there was a mixture of the d- and 1- components, with the 



292 


PROGRESS OF MEDICAL SCIENCE 


1- predominating. These findings are in line with those of Neuberg 
and Luzzatto. It is evident, therefore, that in pentosuria the isomers 
may be mixed in varying proportions. The source of the pentose 
remains obscure. The nucleoproteids of the body cannot be excluded. 
Hunger or insufficient food causes a decrease in the excretion of the 
pentose. Like other observers, the author has found no relation 
between the glucose of the food and pentose excretion. The parallelism 
in the excretion of pentose and total nitrogen determined hourly is 
striking, and suggests an intimate relationship between the pentose 
and protein metabolism. Glucosamine, as shown by the results of 
administering it to the patients, does not increase the amount of pen- 
tose in the urine. IGercker was able neither to confirm nor refute 
Neuberg’s observation regarding the possibility of formation of pen- 
tose from galactose. Following the administration of lactose, there 
was a sharp rise in the quantity of pentose in the urine, which did not, 
however, increase the total output beyond the theoretically possible 
limit. 


On the Production of the so-called “ZellschoUen” in Lymphatic 
Leukemia. — A. Spuler and A. Schittenhelm {Deutsch. Arch. /. klin. 
Med., 1912, cix, 1) report their observations on a case of lymphatic 
leukemia. The so-called Gumprecht’s shells or shadows which one 
sees in lymphatic leukemia, arise from lymphocytes with relatively 
pyknotic nuclei through bursting of the nucleus and mixture of the 
nuclear constituents with those of the cell protoplasm. The study 
of a fresh gland from a patient revealed similar pyknotic cells. From 
this material it was evident that the chromatin of the cells in addi- 
tion to being diffusely distributed is also seen in clumps or plump 
strands. Germinal centres, such as are found in the normal lymphatic 
glands, were not encountered, but areas in which mitoses were numerous 
indicated that there was active proliferation of the cells. Phagocy- 
tosis of red blood cells was observed in the lymphatic glands. A 
gradual transition of these phagocytes to typical eosinophiles, whose 
nuclei later became polymorphous, was observed. These cells originated 
locally and not from bone-marrow elements. 

Disturbances in the Hydrochloric Secretion in Diseases of, and 
following Extirpation of the Gall-bladder. — H. Hohlweg {Deutsch. f. 
klin. Med., 1912, cviii, 255) reports gastric analyses from a large 
number of patients with disease of, or following extirpation of the 
gall-bladder. He found after extirpation of the gall-bladder that of 
39 patients only 10 per cent, had normal hydrochloric acid following 
a test breakfast. The remainder (74.3 per cent.) had either sub- 
normal values or an actual deficit of hydrochloric acid. Three cases 
with normal acid were not included in the series; two suffered from 
gastric ulcer, the third had icterus, conditions frequently associated 
with hyperacidity. Hohlweg believes that a more careful analysis 
would have resulted in the diagnosis of similar complications in some 
of the other cases with normal hydrochloric acid. Among 43 patients 
with closme of the cystic duct or atrophy of the gall-bladder, 84 per 
cent, exhibited a hydrochloric acid deficit, 6 patients had subacicmy, 
and only once was the hydrochloric acid normal in quantity. The 



MEDICINE 


293 


conditions here are, therefore, analogous to those following extirpa- 
tion of the gall-bladder, and the gastric^ findings are the same. In a 
series of 15 cases of cholecystitis, some with calculi but without closure 
of the cystic duct, hydrochloric acid deficit was found 13 times, and in the 
remainder there was subacidity. Hohlweg next examined the gastric 
contents of dogs before and after cholecystectomy, and the results 
were similar to those encountered in man. In a young married woman 
the gastric contents during an attack of gallstone colic showed a 
hydrochloric acid deficit of 20, total acidity of 32. Thvo stones were 
recovered from the stools. A week later free hydrochloric acid 38, 
total acidity 74 Finally, Hohlweg cites several histories of elderly 
patients with loss of weight, gastric symptoms, and hydrochloric 
acid deficit, in whom a diagnosis of gastric cancer was made. Opera- 
tion showed nothing in the stomach, but there was marked disease of 
the gall-bladder. 

Calcium Metastases and Calcium Gout. — ^M. B. Schmidt (Deutsch. 
med. Woch., 1913, xxxix, 59) has made a careful study of a case pre- 
senting extensive calcification and has arrived at the following con- 
clusions: An excess of calcium in the blood alone can lead to deposition 
of calcium in healthy organs, as shown in Tanaka’s experiments and 
in many cases of calcium metastases in skeletal diseases of man 
without nephritis. This, however, is uncommon in man, for usually 
there exists a nephritis. On the other hand, extensive calcification 
may occur in some parts of the body, without increase of the calcium 
contained in the blood, tlirough resorption from the bone; in such 
cases there is usually, but not always, a nephritis. In these cases 
the author believes that there is not a primary dystrophy but rather 
an altered (lowered) solubility of clacium in the blood. The usual 
participation of the acid-secreting organs in the calcification can 
occasionally be augmented by pathological changes in the tissues. 
In the pathologically predisposed organs — ^lungs, gastric mucosa, 
kidneys, bloodvessels and possibly the myocardium — calcification, 
can occur without preceding pathological changes, as happened 
repeatedly in Schmidt’s case. When necrosis is found after dissolving 
the calcium, Schmidt believes it is to be interpreted as the result of 
the deposition calcium, not the cause. Such a conception is similar 
to the prevailing theory regarding gout, namely, that gouty deposits 
result from a primary disturbance of uric acid metabolism with pre- 
cipitation of salts in healthy tissues and secondary necrosis. There- 
fore, the name calcium gout is appropriate for the condition described. 


A Method of • Differentiating between Ascites and Fluids from 
Ovarian Cysts.— A. Dienst {Miinch. med. Woch., 1912, ILx, 2731) 
alludes to the importance of differentiating at tunes between ascites 
and a flaccid ovarian cyst, if exploratory operation is refused and one 
has to resort to tapping of the abdomen. The appearance of the 
fluid may not be characteristic, for at times the fluid of the cyst closely 
resembles the usual serous ascitic fluid and, on the other hand, a pseudo- 
chylous or chylous ascitic fluid is not unlike man^'’ fluids obtained 
from, cysts. Dienst has found that fibrin is a constant constituent of 
ascitic fluids, while it is absent in the fluids of ovarian cysts. As a 



294 


PROGRESS OF MEDICAL SCIENCE 


qualitative test for fibrin, lie adds to tbe fluid in a test-tube- crystals 
of sodium chloride equal to one-third the volume of the fluid. After 
solution of the salt a flocculent precipitate forms, if fibrin is present. 
The absence of a precipitate indicates that the fluid was obtained 
from a cyst and shows the need of operation. 


SUEGEEY 


UNDER THE CHARGE OF 

J. WILLIAM WHITE, M.D., 

rORMERLT JOHN RHEA BARTON PROFESSOR OF BCRGERT IN THE tJNIVERSITT OF PENNSTL-VANIA 
AND 80R0E0N TO THE TJNIVERSITT HOSPITAL, 

AND 

T. TURNER THOMAS, M.D., 

ASSOCIATE PROFESSOR OP APPLIED ANATOMY IN THE UNIVERSITY OP PENNSYLVANIA,* SURGEON 
TO TH*E PHILADELPHIA GENERAL HOSPITAL AND ASSISTANT SURGEON TO THE 
UNIVERSITY HOSPITAL. 


The Radical Operation for Cancer of the Uterus. — Clark {Surg., 
Gynec., and Obst., 1913, xvi, 255) offers the following summary from a 
review of the literature and from personal experience: The operation 
in expert hands, notwithstanding its high primary mortality, has given 
the greatest of permanent cures of any therapeutic procedure thus 
far suggested for cancer of the uterus. While the above conclusion is 
true, the general adoption of the operation, in view of its dangers and 
difiiculties, is not to be advised until the primary mortality can be 
reduced to a much lower percentage by simplification or perfection 
of details. The abandonment of the extensive glandular dissection is 
justified, because this detail adds to the hazards and does not suffi- 
ciently raise the percentage of permanent cures. The cardinal advan- 
tage of the operation lies, first and above all, in the excision of an 
extensive cuff of vagina and the widest possible removal of the para- 
metria] tissue. There is no middle-of-the-road policy in cancer of 
the cervix. The surgeon would better perform a simple hysterectomy 
or high amputation of the cervix with extensive cauterization than 
to attempt the radical operation if he is not prepared effectively to 
execute its details. The earnest endeavor by many specialists, with 
the improved ultimate cures in a few hands, offers' the hope that a 
fimther simplification and perfection of details in this operation may 
yet make it more generally available. 

Results after the Wertheim Operation for Carcinoma of the Cervix 
of the Uterus. — ^N eel {Surg., Gynec., and Ohstet., 1%1Z, xvi, 293) 
made a studj" of the cases treated at the Johns Hopkins Hospital and 
concluded that the extensive abdominal removal of all uterine cervical 
carcinomas is justified where there is any hope of complete e.xcision. 
An exploratory laparotomy is often necessary to determine whether 



SURGERY 


295 


or not a case is operable. The preliminaiy catheterization of the 
ureters is a valuable aid, especially in fat patients, and does not nec^- 
sarily increase the probability of fistulie or secondary infection of the 
urinary tract. Preliminary cauterization and disinfection of the 
primary growth is advisable in all cases. A horizontal lipectomy in 
obese patiepts decreases the depth of the field of operation and shortens 
the time necessary for its completion. All patients should be kept 
in the Fowler position for several daj'^s, unless this is otherwise contra- 
indicated by symptoms of surgical shock. By improvements in the 
technique of the operation, the primary mortality has been decreased 
from 28.5 per cent, for the first seven years to 11.7 per cent, for the 
last five years. Aside from the discovery of the etiological factor, of 
carcinoma of the cervix of the uterus and its successful elimination, 
the greatest hope lies in the early recognition and wide excision of the 
primary growth. 

The Treatment of Beginning Gangrene. — Bobchardt (Zentralbl. /. 
Chir., 1913, xl, 297) says that the question of when and where to 
amputate for gangrene of the foot is still undecided. Moscowicz 
decided the site by observing the level to which the reactive hyperemia 
of the skin reached, after a temporary removal of the blood from the 
affected limb. In this way he determined how much of the tissues 
were being supplied with blood. Borchardt regards this as a good 
aid in determining to what e,xtent the tissues are being nourished, but 
says that the temporary application of a tourniquet is exceedingly 
painful to some patients, and that in cases with severe arteriosclerosis 
the necessary evacuation of blood and reactionary hyperemia cannot 
be obtained. Its application has little influence in improving the 
condition of the circulation and preventing the gangrene. He employed 
the following method in a man, aged fifty-four years, with senile 
gangrene of the toes and severe pain. After three months -existence 
of the gangrene, two toes had been exarticulated, and later, as the 
gangrene was of the moist variety and there was a phlegmon of the 
foot, amputation in the thigh was performed. It was observed that 
at the site of amputation the femoral artery was almost closed. After 
a very severe struggle he recovered. Then there began in the other 
foot symptoms of beginning gangrene, just as in the first foot, with 
severe pain, cyanosis, etc. As the usual treatment, including elevation 
and moist warmth, failed, Borchardt concluded to employ alternating 
warm and cold baths of the limb to the knee. Two deep buckets were 
filled with water, one at a temperature of 35° C., the other with standing 
Avater. The limb rvas placed in each bucket alternately, for a few 
seconds. The changing from one to the other was repeated in the 
beginning thirty times, later fifty times. Gradually the temperature 
of the water was increased to 50° C. in the one bucket, and in the 
other to that of running lA^ater. These baths were taken morning and 
evening for a week, when the pain promptly disappeared. During 
the baths the leg was always very red and warm. It showed a more 
active hyperemia than ivith the use of the warm water alone. The 
patient has continued the baths for tliree-fourths of a vear, and has 
not developed gangrene in this limb. On the contrary, the circulation 
of the limb shoAvs continuous improvement. The buths stimulate the 



296 


PROGRESS OF MEDICAL SCIENCE 


collateral circulation and can considerably improve the peripheral 
blood supply in the presence of existing gangrene, and thus extend, 
peripherally, the limit of the amputation area. The method should 
not.displace the present methods, as Moscowicz’s method, but should 
amplify them. 


The Diagnosis and Treatment of Gangrene of the Foot.— Mos- 
covncz (Zentralbl, f. Chir., 1913, xl, 507) calls attention to the 
fact that the objections to his method raised by Borchardt, can be 
overcome. He has often found that the application of the tourniquet 
is unnecessary. It suffices in most cases to elevate the affected limb 
for pne or t\^m minutes, in order to render it bloodless. That alone is 
a sign of disturbed circulation, since a mere elevation should not 
produce such a complete anemia. If the limb is then let down it 
slowdy becomes red, but much more slowly than if the arteries are 
normal. In many cases he has allowed the limb to hang dowm ver- 
ticalls’- to favor the return of the blood, and even in this position one 
or several toes have remained pale a long time or persistently. By 
thus changing the position of the limb the same changes in circulation 
can be obtained as by Borchardt’s alternating baths. He has also 
seen in one patient the pain of a deficient circulation moderated by 
the use of Klapp’s suction apparatus, and the beginning gangrene 
probably retarded. He does not doubt that Bier’s method of inducing 
passive hjqjeremia has a similar effect in quieting the pain and improv- 
ing the nourishment. It is probable that the anastomosis of the 
femoral artery and vein will produce a similar effect, the more through 
the stasis due to the ligation of the vein than to the turning of the 
blood stream. 


The Treatment of Beginning Gangrene. — ^F rank (ZentralbLf. Chir., 
1913, xl, 508) confirms the value of Borchardt’s method witli the 
report of a striking case. A soldier suffered from frozen feet, which, 
on both sides, including the low'er thirds of the legs, were edematous, 
cyanotic, cold, and tender on the dorsum of the feet. From the tender 
areas doumward, they were without feeling. There was severe, almost 
unbearable pain in the parts of the limbs involved which had feeling. 
The saving of the toes and middle portions of the feet seemed hardly 
possible. It seemed that a Chopart amputation would be necessary. 
At best a Lisfranc, and at the -worst an amputation in the upper third 
of the leg was in prospect. The alternating baths were tried and 
kept up for six months. The effect was striking. The right foot is 
now sound and useful. On the left side the great toe and a part of 
the plantar fascia were excised for gangrene. All the other tissues 
were preserved. 

The Treatment of the Pyelotomy Wound. — ^Bastianelli {Zeniralhl. 
f. Chir., 1913, xl, 420) says that surgeons are now favoring pyelotomy 
for renal calculi as against neplirolithotomy, but that the social 
technique has not yet received much attention. He believes that u 
the proper indications are observed and the operation properlj per- 
formed, the details of the suture are not particularly important, ine 
wound in the pelvis heals wnthout suture, if there is no obstruction 



SURGERY 


297 


to the outflow of the urine, the infection is not severe, or the wound 
is not too large or irregular. Yet it is not advised that the suture 
should be systematically avoided. The incision may be made directly 
through the fat and pelvic wall, and the closure made by catpt 
sutures which include both layers to the submucosa. This applies 
especially to cases in which the kidney cannot be delivered from the 
wound. In one case a large calculus was exposed through a pelvic 
incision. Because the stone could not be palpated easily, the pelvis 
was well freed from the surrounding fat. After extraction of the 
stone, the sutures used to close the pelvic opening cut through. The 
wound was not superficial and its closure was accomplished by a 
quadrilateral flap taken from the fibrous capsule of the kidney, from 
which the fat was removed. Mayo used the fatty capsule for a similar 
purpose. In cases with stones in the calyces, the pelvis should not be 
explored too much with the finger or forceps, but a radial incision 
should be made directly over the stone through the renal parenchyma. 
The wound can be closed with sutures, and these overlaid with a fatty 
flap with good results. In a mildly infected hydronephrosis, the 
cause of which was a stricture at the upper end of the ureter, the 
pelvis was widely opened, the stricture divided anteriorly, and pos- 
teriorly. The wound was then closed in a transverse direction with 
a single row of sutures, and covered with a broad, fatty flap. Primary 
union resulted. When, because of the depth of the wound and the 
shortness of the pedicle, the kidney cannot be delivered, the fat should 
not be freed from the pelvis, but the incision should be made directly 
on the stone and the wound afterward left unsutured. The surrounding 
fatty tissue applies itself over the wound and closes it. 


The Etiology, Symptomatology, and Pathogenesis of Acute Intes- 
tinal Obstruction. — ^Polacco and Neumann {Deutsch. Zeitschr. /. Chir., 
1913, cxxii, 42), in an operation for an acute intestinal obstruction, 
found the jejunum, at about its middle, strangulated by a long, thin, 
fibrous band, which passed from one coil of intestine to another. In 
this central protion of the jejunum were a number of protuberances 
from the surface of the bowel, each about the size of a pea and rather 
firm in consistency. The strangulated portion of the jejunum was 
encircled by a ring formed by the fibrous band which seemed to be 
formed by the union end-to-end of two elongated and pedunculated 
protuberances, similar to .those found on other portions of the bowel. 
After the division of the band, the serosa at the site of strangulation 
was seen to be smooth, and the distal coils of intestine immediately 
filled with gas. The numerous, peculiar protuberances ivliich were 
most numerous in the direction of the appendix suggested that a 
previous appendicitis combined with a fibrous peritonitis may have 
been responsible for them. The appendix was found posteriorly, 
surrounded by fibrous adhesions which showed the same peculiar 
protuberances found on the intestine. The appendix was removed 
as well as some of the protuberances. The histological examination 
disclosed that the^ rounded ends of the protuberances were made up 
of a connective tissue, rich in nuclei, and had a similar connective 
tissue capsule. Tliere was some necrosis, partial hyaline degeneration, 
and edematous infiltration. The pedicle possessed abundant young 



298 


PROGRESS OF SIEDICAL SCIENCE 


connective tissue and capillaries. It is concluded that there occurs 
an apparently little-known development of organized peritoneal 
exudate, in the form of a pedunculated formation, the end being 
about the size of a pea. Two such bodies may adhere to each other 
and cause a probably post-traumatic (as from blows on the abodmen) 
strangulation of the intestine. In these cases two rare symptoms 
occur; a bradycardia with a pulse of about 52, and a retardation of 
the effect of morphine. The latter is probably due to the adminis- 
tration of the morphine by mouth into a well-filled stomach. A quick 
and easy cure can be obtained by a right-sided operation. 


THERAPEUTICS 


UNDER THE CHARGE OF 

SAMUEL W. LAMBERT, M.D., 

PBOrESSOR OP APPLIED THERAPECTICB IN THE COLLEGE OP PBTSICIANS AND SURGEONS, 
COLUMBIA UNIVERSITY, NEW YDRIT. 


Whooping Cough. Its Treatment with Vaccine. — ^^VILS 0 N (New 
York 3£ed. Jour,, 1913, xcvii, 823) reports a series of 24 children with 
whooping cough treated by pertussis vaccine. He gave the vaccine 
in doses of 20,000,000 to 40,000,000 bacteria. The dosage was con- 
trolled, after the initial dose, by the range of temperature and the 
severity of the cough. The paroxysms diminished in frequency and 
in severity and in some of the children very promptlj’^. The charac- 
teristic whoop disappeared and the cases soon became clinically 
simple cases of bronchitis. The shortest duration of treatment was 
nine days, the longest forty-eight days, and the average twenty-three 
days. 

The Vaccine Treatment of Whooping Cough, — Sill (Amcr. Jour. Bis. 
of OMld., 1913, V, 379) has employed pertussis vaccine for the treat- 
ment of 33 children suffering from whooping cough. He believes that 
the vaccine markedly diminished the number and severity of the 
paroxysms and the amount of vomiting. The dosage of the vaccine 
was regulated more by the severity of the disease than by the age 
of the child. The youngest child treated was one month old and the 
oldest was six 5 'ears. Most of the children were from six months to 
three years of age. The dosage of the vaccine varied from 20,000,000 
in the mild cases to 60,000,000 in the severe cases. The cases that 
were treated early in the disease seemed to respond more quickly 
to the treatment, and the course of the disease was shortened. In all 
cases, however, after one to three injections the number and seventy 
of the attacks were markedly diminished. The children showed 
greater improvement when the vaccine was given in moderately large 
doses at intervals of from one to two days. Sill advises as the correct 
dosage for mild cases 50,000,000 bacteria every other day, and for 
severe cases this same dose every da^^ or 100,000,000 every other 



THERAPEUTICS 


299 


day. The vaccine is given subcutaneously in the abdomen or buttocks, 
and no untoward effects were noted. No inflammation, swelling, or 
constitutional symptoms occurred after the injections. Sill also gave 
the vaccine to children constantly exposed to whooping cough, as a 
prophylactic measure, and none of these children contracted the 
disease. He believes that the vaccine when injected in small doses 
has a certain immunizing action against whooping cough. 

The Effect on the Nervous System of Healthy Rabbits of Large 
Doses of Salvarsan. — Doinikow (Mimch. med. Wocli., 1913, lx, 796) 
writes concerning experiments undertaken to determine whether 
the hemorrhagic encephalitis reported by many different observers 
as a result of salvarsan injections was really due to salvarsan. He 
could determine no histological changes in the nervous system of 
rabbits that received for long continued periods of time considerably 
larger doses than the usual therapeutic doses of salvarsan. Only in 
experiments where distinctly poisonous doses were used (0.11 to 0.15 
gram per kilo) could any alterations in the nervous systems be deter- 
mined. These alterations consisted of congestion and hemorrhages, 
but no thromboses of the cerebral vessels were found. 


Neosalvarsan. — Dreyfus {Munch, med. Woeh., 1913, Ix, 630) says 
that neosalvarsan seems in general to be milder and less intensive in 
its action than salvarsan, therefore salvarsan is to be preferred in the 
treatment of syphilitic diseases of the central nervous system. Dreyfus 
thinks that the combined use of salvarsan and neosalvarsan may be 
of great value in the treatment of many cases of syphilis. One must 
not forget that untoward by-effects occur with the use of neosalvarsan 
in spite of its greater solubility. He emphasizes the importance of 
using freshly distilled water and that the water should be distilled and 
the solutions made in Jena glass. This last precaution is necessary 
because certain by-effects observed after intravenous injections of 
salvarsan have been attributed to the action of alkali from glass. 

Mercury and Salvarsan. — ^F inger (W-ie?i. him. Woch., 1913, xxvi, 
561) says that salvarsan should be used in combination with mercury 
in early syphilis as a means of abortive treatment. He also advises 
the use of salvarsan in tertiary syphilis when a rapid effect is desired. 
Finger, however, believes that salvarsan is not superior to mercury 
in secondary syphilis, and, furthermore, it should not be used as a 
routine measure in the treatment of secondary syphilis because of 
certain dangers. He refers especially to the cranial nerve symptoms 
that have seemed to occur so much more frequently since the use of 
salvarsan and that haye been directly attributed by some observers 
to the salvarsan injections. 


TriyaUn.— Mehliss {DcutscJi. med. Woch., 1913, xxxix, 65) says that 
trivalin is an efficient substitute for morphine in any case where the 
anodyne or sedative action of morphine is desired. Trivalin ha.s no 
untoward action on the heart, respirations, or sensorium of the patient, 
and is, furtliermore, less apt to cause gastric disturbance. Trivalin 
is a combination of morphine, caff eine, and cocaine valerianate. 



300 


PROGRESS OF MEDICAL SCIENCE 


Adigan, a New Digitalis Preparation— Frankel and Kirschbadm 
(Wien. Jdin. Woch., 1913, xxvi, 605) write concerning adigan, which is 
a preparation derived from digitalis. This remedy contains all of the 
active^ principles of digitalis with the exception of digitonin and similar 
saponin-like substances, that have been removed. They claim that 
the preparation, because of this purification, is free from untoward 
by-effects especially those of gastro-intestinal irritation and according 
to their clinical observations the remedy has lost none of the therapeutic 
effects of digitalis. 


The Value of the Karell Diet. — ^^VITTICH (Deutsch. Arch. f. IcUn. 
Med., 1913, cx, 128) gives his findings regarding the worth of the 
Karell diet based upon 100 cases of different forms of heart disease. 
He believes that it causes a marked improvement in practically all 
forms of cardiac disease and considers that the only contraindication 
to its use is the presence of uremic symptoms. Chronic myocarditis 
seems to be more favorably influenced than any other form of cardiac 
disease. Valvular lesions of the heart are next in order as regards 
benefit obtained from the Karell diet. Symptoms of cardiac failure 
in chronic myocarditis are relieved by the dietetic treatment alone, 
but in valvrdar disease it is often neeessary to combine cardiac tonics 
with the Karell method of diet. Cases of cardiac failure due to arterio- 
sclerosis are less favorably influencecl, and those associated with 
nephritis are often very little benefited by the Karell diet. However, 
in some cases of nephritis the diet is of great value in conjunction 
with medical treatment. T\Ten uremic symptoms are present abun- 
dant fluids are indicated, and this necessitates a modification in the 
Karell diet the principles of which are a low chloride content and a 
limited amount of fluid. 


The Treatment of Vincent's Angina. — Citron (Berl. Min. Woch., 
1913, 1, 627) describes two cases of Vincent’s angina that were cured 
promptly by the local application of a 2 per cent, solution of salvarsan 
in glycerin. The intravenous use of salvarsan in one of these cases 
was entirely without effect. 


The Treatment of Local Spirochete Infections by Salvarsan and 
Neosalvarsan. — Gerber (Munch, med. Woch., 1913, Ix, 634) advises 
the use of salvarsan and neosalvarsan in local infections due to spiro- 
chetes, such as Vincent’s angina, simple gingivitis, stomatitis, noma, 
alveolar abscesses, and pyorrhea alveolaris. These remedies may be 
used locally in 5 to 10 per cent, aqueous or glycerin solutions or even 
applied directly to the local lesion in powder form. They may also 
be used intravenously but only for severe cases with general symptoms, 
and for those that resist local treatment. 



PEDIATRICS 


301 


PEDIATRICS 


TINDER THE CHARGE OF 

LOUIS STARR, M.D., and THOMPSON S. WESTCOTT, M.D., 

OF PHII/ADELPHIA. 


The Treatment of Scarlet Fever with Neo-salvarsan— Louis 
Fischer {AtcJivd f. PediatHcs., 1913, xxx, 352) refers to the experi- 
ments in treating scarlet fever with intravenous injections of neo- 
salvarsan. Some cases of this disease give a positive Wassermann 
reaction and this has led a number of investigators to try the above 
treatment. Lenzmann, Schreiber, and others describe advantages 
by this treatment whiph indicate that a decided antipyretic effect is 
soon noted after the injection, and that there is a decided exfoliation 
of the necrotic membranes with tendency toward convalescence and 
absence of fatal complications. Infants received 0.1 gram, older 
children, 0.2 or 0.3 gram by intravenous injections. Some children 
required three or four injections. Arsenic alone, as in Fowler’s solu- 
tion was given in scarlet fever without result. Neosalvarsan is readily 
dissolved in water, shaking is not necessary, and it is a much more 
simple preparation than salvarsan. Fischer used this treatment in 
five cases of scarlet fever, all of which were septic and with a fatal 
prognosis. The Wassermann reaction was negative in three, one 
probably positive, and one unreported. Injections were given intra- 
venously, the jugular vein being the best selection for giving the 
remedy. The dose employed was 0.2 gram in 40 c.c. of plam sterile 
water. No reaction such as shock, acute febrile attack, or rash followed 
the injection. Three of the cases died, but showed the antipyretic 
effect of the neosalvarsan. One case improved, following the injection 
and recovered, the credit of this being franldy given to the effect of 
the drug. One case was prolonged and is still in the hospital, but with 
a grave prognosis. While too early to make definite statements as 
to this treatment, enough has been accomplished to merit an extensive 
trial of this drug in scarlet fever. 

The Etiology of Measles. — ^Jerome S. Leopold {ArcJiiv. of Pedi- 
atrics, 1913, xxx, 356) gives a resume of the work so far done in deter- 
mining the etiology of measles. Anderson and Goldberger have 
proved the presence of the infectious agent in the blood and in the 
nasal and buccal secretions. Injection of blood from a measles case 
into monkeys caused characteristic eruption Avith fever, coryza, 
bronchitis, and often pneumonia. The infectivity of the blood was 
greatest shortly before the eruption of measles appeared, lasted twenty- 
four hours, and rapidly diminished. Hektoen successfully reproduced 
the disease in adults by subcutaneous inoculation with blood taken 
from measles cases during the first thirty hours of the eruption. The 
former investigators also obtained positive results by applying secretions 
from the mouth and pharynx of measles cases to the mouth and 
pharynx of monkeys. All attempts to inoculate monkeys with epi- 



302 


PROGRESS OF MEDICAL SCIENCE' 


dermal scales of measles have failed. The virus is ultramicroscopic; 
desiccation is resisted for twenty-four hours, freezing resisted for 
twenty-five hours, and inf activity is destroyed by heating to 55° C. 
for fifteen minutes. All attempts to grow the virus are unsuccessful. 

The Cause and Prevention of Adenoid Growths in Children.— 
H. E. Jordan — Archiv. of Pediatrics, 1913, xxx, 468) believes that the 
enlargement of tonsils and adenoid growth are the effect of a funda- 
mental, controllable factor, and that the concomitant morbid symptoms 
are indirectly the result of the enlargement. Increased functional 
demand causes enlargement of the structures and this demand is 
caused by mouth-breathing, induced by chronic nasal colds in children. 
The solution, then, is to promote nose-breathing, which is largely a 
matter of preventing colds. The ultimate factor in the production of 
colds is the almost universal inattention to damp linen. Small chil- 
dren are allowed to go “wet” for hours, especially at night. The 
series of links are damp clothes, exposure, with evaporation and 
possibly chill; nasal cold with obstruction of the nostrils, mouth- 
breathing and hj-pertrophy of lymphoid tissue. Mothers should be 
more carefully instructed in keeping children dry, and means should 
be devised to make this condition easier to regulate. 


O BSTETEICS 


UNDER THE CHARGE OF 

EDWARD P, DAVIS, A.M., M.D., 

PBOFESSOR OF OBSTETRICS IN THE JEFFERSON IIEDICAI. COLLEGE, PHILADELPHIA. 


Hebostiotomy, — ^K rfwsky {Monatschr. /. Gcbiirts. u. GynUh., 1913, 
xxxvii. No. 4) reports the case of a patient whose first labor was 
successfully terminated by forceps. In the second labor the child 
was stillborn; in the third labor a living child was obtained by forceps; 
and in the fourth labor hebostiotomy by Doderlein’s method was 
done, and an unusually large and well developed child was delivered 
by forceps. This child died at four months. The pelvis had been en- 
larged by the previous operation, but hebostiotomy was repeated upon 
the right side, and a large living child wms again delivered by forceps. 
This child died two years aftervmrd. Eight months after the second 
operation the .r-rays revealed the fact that but partial formation o 
bony tissue had occurred. The patient again came under observation 
when eight months pregnant, came into labor, and was delivered y 
Cesarean section, followed by sterilization. Both mother and cm 
made a good recovery. Kriwsky has collected a considerable num er 
of reported cases, showang 76 spontaneous births after hebostiotom}", 
26 repeated operations, and 15 cases in w^hich Cesarean section wa 
substituted. He believes that the operation has a place m ^ _ 
procedures, and that the true conjugate should be not less tua 



OBSTETRICS 


303 


cm. He would not select it for cases in whicli the true conjugate was 
less than 7 cm., and preferably in multiparfe. The operation may be 
substituted for perforation if the surroundings are favorable for an 
aseptic operation. Dbderlein’s method is preferred, and no especial 
complications are to be expected during tlie puerperal period. Bony 
uinion through the severed ends forms very slowly, and in many 
cases does not develop. Permanent enlargement of the pelvis rarely 
occurs. 


The Influence of the X-rays upon the Membranes.— Kawasoye 
(Zentralbl. /. Gynak., 1913, No. 14) has experimented upon_ pregnant 
animals to ascertain the effect of the .r-rays. No alterations were 
found in the membranes in the wall of the uterus, but the results of 
the .T-rays were in 3 out of 7 cases the production of abortion or pre- 
mature labor. The liver and spleen of the fetus showed necrosis. 
Caution should accordingly be exercised in using the .r-rays upon 
pregnant patients. 

Hematoma of the Abdominal Wall in Pregnancy. — Vogt {Zentralbl. 
/. Gyn'dlc., 1913, No. 14) reports the case of a young woman in her 
second pregnancy, who gave birth to a normal infant in spontaneous 
labor. Several hours after delivery the patient complained of severe 
pain above the symphysis. No alteration in the skin of the abdominal 
wall was evident. The uterus was at the umbilicus, well contracted, 
and little sensitive. Above the symphysis were two superficial tumors 
which could be moved upon the subjacent tissue. On further exami- 
nation it was found that these were hematomas at the inferior extremity 
of the recti muscles. The tumors Increased somewhat in size, and 
their absorption proceeded slowly. Four weeks elapsed before the 
patient was in normal condition. There was no explanation for their 
formation. 


The Electrocardiogram in Pregnancy, — Rudner {Zentralbl. f. 
Gyndk., 1913, No. 13) has used the electrocardiogram in studying the 
condition of the heart in pregnant patients. Characteristic tracings 
were obtained which practically confirmed previous clinical obser- 
vations. The value of the method lies in its graphic demonstration. 

Uterus Bicornis Causing Chronic Transverse Position of the Fetus. 
—Von Klein {Zentralbl. f. Gyndk., 1913, No. 13) reports 6 cases of 
uterus bicornis with transverse position of tlie fetus treated by version, 
and one by Cesarean section. It seems more than probable that this 
uterine abnormality is a frequent cause for transverse position. 

The Correlation of the Internal Secretions of the Ductless Glands 
and the Genital Functions of Women.— Bell {British Med. Jour., 
April 5, 1913) concludes in two lectures upon this subject, that although 
tJiere are great variations in the structure of the ductless glands in 
different mammals, the total functional result is the same, so far as 
the genital processes are concerned. The individual metabolism of 
the mother and the metabolism of her reproductive functions are 
completely interdependent. While the ovaries furnish ova and keep 



304 


PROGRESS OF inSDICAL SCIENCE 


active tlie rest of the genital structures and functions, they are also 
concerned in keeping the other members of the ductless glands active, 
in relation to the necessity of the reproductive organs. When the 
reproductive functions cease, and the ovaries atrophy at the meno- 
pause, the general relationship is temporarily deranged, and various 
disturbances follow. It is only by the careful study of each individual 
case that one can learn in what manner the balance has been destroyed. 
The basis of treatment for the disorders of the menopause must be 
found in the disarrangement between the ovaries and the remaining 
ductless glands. Some patients are benefited by thjToid extract at 
the menopause; some by pituitary extract; others by various com- 
binations. There is evidence that liyperplasia of the suprarenal cortex 
can offset the influence of the ovary and produce some of the secondary 
characteristics of the male in the female body, and partially change 
the development of the genital organs. The ovary influences the 
general metabolism in relation to its primary reproductive functions. 
The thyroid, pituitary, and suprarenals influence the development 
and preserve the integrity and activity of the genital organs. The' 
thymus and possibly the pineal gland seem to prevent sexual pre- 
cocity. All the ductless glands control metabolism in proportion to 
the necessities from the genital functions. When these cease the 
characteristic phenomena of the menopause develop. On the con- 
trary, insufficiency of the thyroid, pituitary, or suprarenals, cause 
the genital functions to cease and the uterus to atrophy. 

The Ovary as an Organ of Internal Secretion. — Graves {Ainer. 
Jour. Obstet., April, 1913) believes that in the present state of our 
knowledge anatomical evidence makes it probable that the ovary is 
an organ of internal secretion. Infantilism is not a result of ovarian 
deficiency, but is a manifestation of defieient development in which 
the ovary may or may not share. After sexual maturity the ovary 
has a trophic influence over the other genital organs. The ovaries 
preside over menstruation by an internal secretion which acts upon 
the endometrium. Abnormal uterine hemorrhage may be due to 
increased secretion of the ovaries. The transplantation of ovarian 
tissue has not proved to be of great practical value in the surgical 
treatment of gynecological cases. When the ovaries are removed 
from mature women, vasomotor disturbances follow in 80 per cent, 
of cases. The removal of the ovaries does not directly cause definite 
disturbance of the nervous system. If these symptoms are present, 
they are due to other causes. Ovarian extract is very valuable in 
treating the vasomotor disturbances which follow the removal of 
the ovaries. In other gjmecological conditions it is of little importance. 

The Mucous Channels and the Blood Stream as Alternative Routes 
of Infection. — ^B ond {British Med. Jour., March 29, 1913), in a very 
interesting paper upon this subject, with illustrations, concludes 
that when an organism like the Bacillus coli comrnunis reaches e 
pelvis of the kidney by ascending the urinary tract, it produces symp- 
toms in effect which differ from those caused by the same germ a 
reaches the kidney by way of the blood stream. The organism seems 
to adapt itself to a mucous and urinary environment, on the one a , 
and a blood or lymphatic channel, on the other. 



GYNECOLOGY 


305 


GYNECOLOGY 


UNDER THE CHARGE OP 

JOHN G. CLARK, M.D., 

PEOPE8SOR OP OTNECOLOQT IN THE HHIVEBSITY OF PENNSYLVANIA, PHILADELPHIA. 


Treatment of Postoperative Retention of Urine. — ^The use of 
pituitrin in the treatment of urinary retention in women after opera- 
tions and in the puerperium is very strongly recommended by Ebeler 
{Zeitschr. f. gyn. UroL, 1913, iv, 55), who has tried it in 21 puerperal 
and 24 postoperative cases, with excellent results, finding that by 
its use he was able in all cases to avoid catheterization. _ All the injec- 
tions were given deep into the muscles; they are best given when the 
bladder is fairly full, and the patient feels the necessity of having it 
emptied. An injection of pituitrin given under these circumstances 
is nearly always followed within five minutes to ten minutes by an 
increased desire to micturate, tliis usually culminating in a spon- 
taneous evacuation of the bladder; in some instances, however, this 
does not take place until after the lapse of a few hours. If the injec- 
tion is given with the bladder only about half full, the action is less 
marked, but is still distinctly noticeable; if given when the bladder 
is empty, there is no appreciable effect whatever. Ebeler does not 
advise giving an injection upon the first intimation on the part of 
the patient of a desire to pass water, 'but thinks it is better to Avait 
until there is very distinct discomfort in the bladder region. When 
once a voluntary micturition has been secured, it has seldom been 
found necessary to repeat the injection; in only 8 of Ebeler’s 45 cases 
was a second dose required. In all instances the bladder Avas com- 
pletely emptied, so far as could’ be determined by percussion, Avithout 
using the catheter. 


Treatment of Uterine Hemorrhage by the X-rays. — Although great 
activity along this line has been manifested in recent years throughout 
Europe, but comparatively little has appeared in the American litera- 
ture upon the subject; a paper recently read before the Philadelphia 
Obstetrical Society by Pfahler (Amer. Jour. Obstet., 1913, Ixvii, 860), 
reporting a series of cases with exceedingly encouraging results, is 
therefore of considerable interest. This report comprises 23 cases 
of more or less severe uterine hemorrhage; in 21 of the patients fibroid 
tumors were present, the other 2 were examples of “metropathia,” 
without demonstrable cause. In most instances a marked diminution 
in the size of the tumor was noticed folloAving treatment, in addition 
to the effect produced upon the hemorrhage; indeed, in 12 out of the 
16 patients AAdio have ceased treatment, the tumor has entirel 5 '' disap- 
peared. In 2 of these patients, the groAvth extended to the umbilicus, 
but after five and four years respectively it can no longer be found. 
Pfahler says that he has never seen malignant degeneration of a 
myoma folloAA'^ .r-ray treatment, and does not consider the danger 
from this possibility Amry great. T\Tiere the patient is Amry anemic. 



306 


PEOGRESS OF MEDICAL SCIENCE 


lie always insists on rest in bed after the first series of treatments, 
as these are often followed by somewhat increased hemorrhage. In 
one of his cases treatment was followed by amenorrhea and disap- 
pearance of the tumor; after a time, however, menstruation was 
reestablished in normal amount, and the patient has continued in 
perfect health. The treatment is given in series of from three to nine 
applications, generally on successive days, each series being followed 
by an intermission of about a month. If bleeding has not ceased 
after six treatment-series, the case should be considered unsuited for 
this form of therapy, and surgical intervention considered. Pfahler 
believes that the best results will be obtained if the cases are carefully 
selected by a trained gynecologist and treated by an expert Ront- 
genologist. He does not, as a rule, advise applying .r-ray treatment 
to Avomen aged under forty years, although in exceptional instances 
this may be permissible. 


The Use and Abuse of the Curette. — In an article wdiich Frank 
states is intended primarily for the general practiiio7ier, he {Neio York 
Med. Jour., 1913, xcvii, 808) calls attention to the excessive fondness 
which apparently still exists among the profession for the curette, a 
condition which not infrequently leads to serious consequences. In 
running over the records of 2000 consecutive cases seen in his dispen- 
sary service, Frank has found that considerably over one-fifth of these 
women had at some time or other been curetted; several of the patients 
upon whom this operation had been performed were unmarried, or 
had not yet reached the age of puberty. Of 721 cases of abortion, 
either spontaneous or induced, nearly every second patient had been 
curetted; in 20 instances the operation had been performed post 
partum, in 32 cases sterility was the indication, in 36 menorrhagia or 
metrorrhagia, and in 40 leukorrhea. Frank considers that in practically 
all these cases the curette had better have been left unuped. Whereas 
50 per cent, of the cases curetted post abortum showed subsequently 
inflammatory lesions of the adnexa or parametrium, these were present 
in only 12 per cent, of an equal number not curetted. To curette 
post partum is, in Frank's opinion, never justifiable, as it only breaks 
down the natural defenses of the uterus, and opens wdde paths of 
invasion to infectious organisms. While careful and light curettage 
post abortum may be justifiable, and at times even necessary when 
the patient is in a hospital, surrounded by all the facilities which it 
provides, Frank believes that the general practitioner will come out 
much better in the long run if he refrains from applying this treatment 
under the unfavorable conditions usually found in private practice, 
and adopts almost exclusively the purely expectant policy in treat- 
ing these cases. He believes, further, that in the small percent- 
age of cases in which curetting apparently does good in sterility or 
“endometritis” (i. e., leucorrhea), it is really the preceding duaiaiion 
which has been of benefit. Frank does not wish to be misunderstood 
as desiring to banish the curette altogether, since it has, when proper y 
used, a position of vital importance in our gynecological armamen- 
tarium; this position is as a diagnostic rather than as a therapeu ic 
weapon, however. In cases of irregular bleeding— especially 
climacteric and preclimacteric menorrhagias and metrorrhagias i 



OTOLOGY 


307 


should be obligatory on the attending physician to use the curette,, 
but not so much with the expectation of_ curing the condition as of 
removing material for histological examination. He beliei’^es that 
were the profession as a whole fully alive to the importance of this 
point, the public could be educated within a couple of years to demand 
such an examination, just as they now demand a Wassermann test 
in suspected syphilis. 


OTOLOGY 


CLARENCE J. BLAKE, M.D., 

PROFESSOR OF OTOLOGY IN THE HARVARD MEDICAL SCHOOLi BOSTON. 


The Function of the Auricle. — The widely varying opinions as to 
the acoustic and protective value of the human auricle are carefully 
presented by H. Franks {Beitragc ziir Anatoviie, Phjsiologie, Path- 
ologie, tmd Therapie des Ohres, der Nase, und des Halses, vi. No. 3, 219) 
with a degree of detail which makes, in each instance, an abstract 
of the conclusion drawn from the recorded observation of the individual 
writer. The papers which form the basis of Franke’s review, twenty- 
five in number, range from Buchanan in 1828 to the present day, and 
are widely divergent in their deductions; in some instances the auricle 
being regarded as of importance in the collection, the reflection, the 
reinforcement of sound waves, and as a resonator for certain tones 
and, moreover, of definite assistance in the determination of the 
direction of a sound source. Burkner, for example, in a case in which 
one auricle had been lost through accident, without injury to the 
middle, or internal ear, the tragus remaining uninjured, the hearing 
for the watch was found to be equal in the two ears so long as the 
sound source was held opposite the tested ear in the line of the long 
avis of the external auditory canal; a departure from this line, in any 
direction, exhibited a much more rapid falling off in the recorded 
hearing distance of the ear without an auricle, the conclusion of the 
observer being, naturally, that the auricle is important for the percep- 
tion of sound by its collection of sound waves and their corresponding 
transmission of the sound waves to the middle ear mechanism and 
the perceptive apparatus. Burkner also found’that with only the sound 
ear exposed the patient was accurate in his determination of the 
direction of a sound source, but that this was by no means the case 
when the perfect ear was tightly stopped and an attempt made to 
determine the direction of a sound source by means of the mutilated 
ear only. When both ears remained free the determination of the 
direction of a sound source was, in the majority of instances, correct, 
but more mistakes were noted when the sound came from the direction 
of the mutilated ear. Gradenigo drew similar conclusions from a 
corresponding case, observed by him, and confirmed the observations 
as to the^ lesser ability to determine the direction of a sound source 
on the aftected side. Schaefer regards the human auricle as of funda- 



308 


PROGRESS OF MEDICAL SCIENCE 


mental and conclusive value to the hearing as a whole, reporting 
instances of progressive depreciation in the hearing power where the 
auricle had been mutilated or removed, and corresponding improve- 
ment in the hearing when means were taken to convey sound directly 
into the afiPected ear. Johannes Muller and Gigel, with other observers, 
concluded that the principal medium for the transmission!: of sound 
waves falling upon the auricle was through the substance of the 
auricular cartilage itself and its consequent conveyance along the tubal 
cartilage of the external auditory canal to the middle ear, instancing 
the hearing for tones of low pitch in auscultation either by contact 
of the auricle directly with the body of the patient or with a directly 
applied stethoscopic tube. Out of the material afPorded by these 
observations, with the addition of his own, Franke arrives at the con- 
clusion that the auricle has one well assured function, namely, the 
protection of the deeper portion of the ear, in which protection the 
tragus, extending oAmr the meatus, plays an important part, but he 
makes no allusion to the caloric value of the auricle, the increase in 
its circulation when exposed to cold air serving to counteractively 
increase the temperature of the external auditory canal and helping 
to maintain the normal body temperature in the drumhead and in 
the middle ear. Franke further concludes, on the whole, that if the 
auricle in man is not to be regarded as a physiologically worthless 
rudimentary organ, it must be admitted to have but small value in 
the light of its contribution to the function of hearing. 


The Relationship between the Hearing for the Whisper and the 
Conversational Tone. — Upon the basis of the observations in regard 
to functional hearing tests of Wolf, Bezold, Siebenmann, and others, 
Julius Veis (Archivf. Ohrmheilkunde, 1913, xc, 3) draws comparisons 
between the audible values of the human voice in ordinary conver- 
sational use and in a whisper, the former as representing tones of 
medium low and the latter tones of medium high pitch. For purposes 
of uniform testing in whispering, numerals were selected according to 
their presentation of low or high-pitched vowel sounds, thus affording 
a condensed means for speedy and accurate comparison in individual 
cases. The difficulty of determination of the relative pitch of whis- 
pered vowel sounds was confirmatory of the earlier observations of 
0. Wolf, this being in part due to the fact that the toneless whisper 
ranges far above the medium fundamental tone of ordinary speech, 
the latter being definitely a test for the medium low tones and the 
former for the medium high tones of the auditory scale; under these 
circumstances the voice test is both valuable for itself in the grea 
majority of cases, and as an adjunct to the other forms of hearing 
test in common use. From his investigations carried out in 
of impairment of hearing from causes pertaining in both the mi^ e 
and the internal ear, Veis draws the following conclusions; ^ (1) 1“^ 
test of hearing by means of the conversation form in comparison wit i 
the parallel test in a whisper is important in cases of marked impair- 
ment of hearing (whisper less than Im), in reference to diagnosis, 
therapeusis and prognosis; a test with the whispered voice alone 
no adequate determination of the actual hearing power. ^ (2) In case 
of otosclerosis and in many cases of past suppurative mnamma i 



OTOLOGY 


309 


of the middle ear the conversation tone was heard at a not much 
greater distance than the whisper, while in cases of labyrinthine 
deafness and in the exudative process of middle ear affection the 
conversation tone was heard far better than the whispered voice.^ (3) 
When the conversation tone is heard much better than the whisper 
there is more promise of improvement in the general hearing under 
treatment. (4) Improvement in hearing, in consequence of middle 
ear inflation, is evidenced mainly in regard to the conversation tone, 
the hearing for the whisper being either not at all or only slightly 
improved. 

Clinical Observations upon a Hitherto Undescribed Form of 
Tuberculosis of the Middle Ear. — ^From a large material of cases of 
tuberculosis Joergen Moeller (Zeitschr. f. Ohrenheilkunde, Ixiv, 4) 
selected a series of cases of middle ear tuberculosis presenting symp- 
toms the evidence and import of which seemed to have been heretofore 
unappreciated. In tuberculous patients who complain of no more 
serious symptoms than subjective noises or a diminution of hearing, 
objective examination shows in the early stage of the middle ear 
implication, appearances corresponding to those of a simple, acute, 
suppurative, middle ear process. The drumhead was distended, the 
long process of the malleus lay in a furrow or was entirely concealed 
by the distention of the drumhead outward, the color of the mem- 
brane was a yellowish-white, dull, and not diffusely injected as is 
the case in simple acute inflammation of the middle ear, but instead, 
against the dull yellowish white background there was a network of 
distended bloodvessels radiating from the manubrial plexus. Infla- 
tion of the middle ear by means of the air douch gave only temporary 
and partial relief from the subjective symptoms and paracentesis 
revealed a dry incision through a generally thickened membrane, an 
opening which was usually entirely healed on the following day. As 
a rule, in a majority of the cases, the inflammatory process either 
resolved or localized itself in one spot, or another of the drumhead, 
as a small and limited ulceration confined to only one layer of the 
drumhead while in other instances the necrotic process was more 
general in its attack, the drumhead became perforated, and the sub- 
sequent course of the case was that of the ordinary suppurative middle 
ear tuberculosis. The implication of the middle ear throughout 
evidenced itself as primarily a diffuse tuberculous inflltration of the 
drumhead and of the tympanic mucosa, this view being supported 
by the histological examination of excised portions of the drumhead. 

Temporary Glycosuria in the Course of Suppurative Middle Ear 
Disease. ^Upon the basis of the folloAving experience Alfred Zimmer- 
M.VNN {Zeitschr. f. Ohrcnhcilhundc, Ixvii, Nos. 3 and 4, 217) was led to 
make an extended review^ of the literature concerning the question 
of the relationship of the presence of sugar in the urine for short 
periods, during the progress of a suppurative process in the middle 
ear. The patient was a man, aged twenty-four years, who, in sequence 
of a cauterization of the left inferior turbinate, had, two days later, 
an acute inflammation of tlie right, middle ear from which para- 
centesis of the drumhead liberated a serous discharge; there was also 



310 


PROGRESS OF MEDICAL SCIENCE 


a light implication of the left ear; on the following day there was a 
slight further rise in temperature and a copious purulent discharge 
from the right ear exhibiting, both microscopically and by culture, 
staphylococcus, streptococcus, and psuedodiphtheria bacillus. The 
congestion of the left middle ear rapidly decreased with an ultimate 
return to normal, but in the right ear continued and increased, but 
without evidence of intracranial complications. The urine, as examined 
when the case was first seen, wns practically normal, without a trace of 
albumin or of sugar, but on the seventh day, under the same dietary 
conditions as before, a large percentage of sugar was found in the 
urine. In the subsequent course of the case, with a gradual decrease 
in the local, aural, disturbance, the percentage of sugar proportion- 
ately decreased, and finally disappeared not withstanding a resumption 
of the ordinarj’’ diet which had, for a time, been suspended. Begin- 
ning with the investigations of Claude Bernard upon the effect of 
injury in the region of the floor of the fourth ventricle upon sugar 
elimination, and following through the clinical literature of the sub- 
ject, Zimmermann concludes that suppurative inflammation of the 
middle ear, even when it does not extend beyond the boundary of 
the temporal bone, especially at the acme of its clinical evidence of 
activity, may be the cause of a transitory glycosuria which should 
in no way be confounded with, or lead to an oversight of, the really 
serious renal lesion of which this symptom might be an evidence. 


PATHOLOGY AND BACTERIOLOGY 


UNDER THE CHjiKGE OF 

JOHN McCRAE, M.D., M.R C.P., 

LECTDREB ON PATHOLOQT AND CLINICAL MEDICINE, MC GILL UNIVERSITY, MONTREAL; BOMB TIME 
PROPESSOR OP PATHOLOGY IN THE UNIVERSITY OP VERJIONl, BURLINGTON, VERMONT', 
SENIOR ASSISTANT PHYSICIAN, ROYAL VICTORIA HOSPITAL, ilONTBEAL. 


The Bordet-Gengou Bacillus of Whooping Cough. — Mallory, 
Hornor, and Henderson {Jour. Med. Research, March 1913) have 
completed the proof according to Koch's postulates that the recently 
described bacillus is the actual cause of whooping cough. They have 
been able from sputum to obtain pure cultures, to produce the lesions 
which they have shonm to be characteristic in young animals, and m 
four instances have, obtained the organism again from these subjects 
in pure cultures. They consider that a vaccine or antitoxin is probably 
within reach. 

The Effect of the Spleen and Splenic Extract upon Malignant 
Tumors. — Oser and Pribram, from Prof. v. Eiselsberg’s clinic 
{Zeitschr. /. Exper. Path. .u. Thcr., January, 1913, Band xii, Hett 
undertook experimental work upon the effects that can be produce 
on malignant tumors by the absence of the spleen as well as by sp enic 



PATHOLOGY AND BACTERIOLOGY 


311 


extracts. Oestricli had supposed that chondroitin-sulphuric acid was 
responsible for certain favorable effects on carcinomatous growths, 
and Oser and Pribram used his medium, composed of sodium chon- 
droitin-sulphate and /3-eucaine, upon a series of patients, but were 
entirely disappointed by the lack of good results. Considering that 
the spleen is almost as efficient as the bone marrow as a site of forma- 
tion for antibodies, and that agglutinins can be demonstrated in the 
spleen earlier than in the blood, Braunstein obtained good results 
by removing the sterile spleen from cancer-mice and injecting the 
extract of the spleen in salt solution into other cancer-mice. He first 
used mice which had been injected with carcinoma, and removed 
the spleen before any tumor appeared. Of other cancer-mice so 
injected, one-fourth of those surviving showed tumor recession. One- 
third died of the injection. When he took the spleen from mice with 
well developed tumors, 6 of 15 mice injected died, but 5 of the remaining 
11 showed recession. Yet again, he took the spleen from mice injected 
intraperitoneally repeatedly with carcinoma and sarcoma extract, 
four to six days earlier; this was injected into 45 cancer-mice with 3 
deaths; in 6 recession of growth occurred, in 3 cessation of growth. 
Of 7 sarcoma-rats similarly tested, 6 showed regression. Braunstein’s 
conclusions were that the spleen possesses a highly developed power 
of resistance against tumor growth, while, on the contrary, splenec- 
tomized animals are more liable than normal animals to the inroads of 
malignant growth. Rohdenberg and Johnston made observations 
that were parallel upon the thymus, pancreas, spleen, hypophysis, 
and testes, showing that after extirpation of the thyroid, thymus or 
testes the animal had a lessened resistance to carcinoma. Oser and 
Pribram’s experiments support the views of Braunstein, and they 
show measurements and pictures of tumors indicating regression, 
and also the comparatively quicker growth of tumors in previously 
splenectoniized animals. Spleen extract was efficient in the possession 
of antibodies, while blood removed at the same time failed to show 
such qualities. 


Anaphylotoxin, Peptotoxin, and Anaphylaxis. — Besredka, 
STR6BEL,_and Jtjpillb {Aimal. de Vlmt. Pasteur, March, 1913, xxvii, 
No.^ 3) give details of some interesting experiments upon anaphylo- 
toxine, a name which Friedberger gives to what he supposes to l 3 e the 
active agent in anaphylaxis; he considers that the anaphylactic state 
of an animal with regard to an albumin is due to the appearance of 
precipitin in its serum, and anaphylactic shock is the result of com- 
bination of the precipitin with the alexine of the animal. This being 
the case, one had only to inject an unprepared animal with the test- 
tube preparation of precipitin and alexin, and the result showed that 
the intravenous injection was highly toxic to the animal. This sub- 
staime Friedberger called anaphylotoxine. In the words of Besredka, 
Strobel, and Jupille, ^the fortune of anaphylotoxin was made, and 
almost any bacillus, however slightly pathogenic, could apparently 
be proved to possess its anaphjdotoxin.” We were in a fair way to 
find that even infectious diseases were the work, not of specific patho- 
genic agents so much as of anaphylotoxin. Besredka, Strobe), and 
Jupille have endeavored to stem the triumphant march of the ana- 



312 


PROGRESS OF ilEDICAL SCIENCE 


phylotoxins by attempting to find out if they are the specific poisons 
of anaphylaxis. To obtain a microbic anaphylaxis, it was necessary 
to make an alexin act on microbes and specific serum; it was then 
discovered that specific serum was unnecessary, and that it sufficed 
to make the alexin act on the bacilli alone. Still later the authors have 
simplified the technique by withdrawing from it the bacilli, making 
the alexin act on the sterile medium without bacilli; they have obtained 
thus a toxic substance which has all the characters of anaphylotoxin. 
This they have called peptotoxin because of its relationship with 
peptones, in preference to anaphylotoxin, since they consider it to 
have no relation to anaphylaxis. For purposes of comparison they 
have taken guinea-pigs injected with anaphylotoxin, peptotoxin, and 
peptone, followed by bacterial vaccination in progressively increasing 
doses quickly administered. The results have been to show that 
anaphylotoxic shock and anaphylactic shock are two entirely different 
things, and. that vaccination following anaphylotoxin, peptotoxin, 
and peptone, presents well-defined characters common to these three 
substances, and very distinct from the characters which designate the 
ordinary anti-anaphylaxis. The toxic effects produced by the peptone 
and its derivatives may exactly copy the effects of anaphylaxis, but 
the '' peptonic shock” does not in the guinea-pig produce any pro- 
tection against anaphylactic shock. Typhus anaphylotoxin can be 
injected safely into the venous system in guinea-pigs in increasing 
doses, injected at short intervals, and the same is true of peptotoxin 
and of the peptone; in all three cases, however, the weight of the 
animal and the dose of poison must be reasonably coordinated, and 
for all three it is likewise necessary that the venous circulation should 
be used. Anti-anaphylactic vaccination does not possess these 
characters, and Besredka, Strobel, and Jupille conclude that the 
phenomena which they attribute to anaphylotoxin, peptotoxin, and 
peptone have nothing in common with true anaphylaxis. We are 
thus, they think, carried back once more to our original conception 
of anaphylaxis and anaphylactic shock, which excludes the idea of 
intoxication by a particular substance such as anaphylotoxin. They 
compare the process of desensitization which occurs during the ani^ 
phylactic state to a rapid decoloration or decompression: when such 
decompression or decoloration occurs in a gradual and_ progressive 
manner, the process of anti-anaphylaxis is being accomplished. 


Notice to Contributors. — All communications intended for insertion m 
the Original Department df this Journal are received only with the distinct 
understanding that they are contributed exclusively to this Journal. 

Contributions from abroad written in a foreign language, if on examination 
they are found desirable for this Journal, will be translated at its expense. 

A limited number of reprints in pamphlet form, if desired, will be furms e 
to authors, •provided the request for them be •written on the manuscript- 
All communications should be addressed to — 

Dr. George Morris Piersol, 1927 Chestnut St., Phila., Pa., U. S. 



CONTENTS 


ORIGINAL ARTICLES 

A Lobar Form of Bronchopneumonia of Long Duration, Occurring in 

Children and Young Adults 313 

By David Riesman, M.D., Professor of Clinical Medicine in the 
University of Pennsylvania. 

The True Value of Operation for Cancer 321 

By Edward Milton Foote, M.D., Visiting Surgeon to the New 
York Skin and Cancer Hospital. 

Therapeutic Artificial Pneumothorax 330 

By Herbert Maxon King, M.D., Physician in Chief, and Charles 
Wilson Mills, M.D., Associate Physician to the Loomis 
Sanatorium, Liberty, New York. 

The Diagnosis of Tuberculosis of the Kidney 352 

By Floit) E. Keene, M.D., Instructor in Gynecology, University 
of Pennsylvania; Assistant Gynecologist to the University Hos- 
pital; Gynecologist to the Chestnut Hill Hospital, Philadelphia, 
and John L. Laird, M.D., Assistant Instructor in Genito- 
urinary Surgery, University of Pennsylvania; Assistant Surgeon 
in Genito-urinary Diseases to the University Hospital; Asso- 
ciate in Serology, William Pepper Clinical Laboratory, Phila- 
delphia. 

Invagination of Meckel’s Diverticulum Associated with Intussusception; 

Report of a Case, with a Study of Recorded Cases .... 364 
By Arthur E. Hertzler, ,M.D., and Edward T. Gibson, M.D., 
Kansas City, Missouri. 

Spinal Gliosis Occurring in Three Members of the Same Family, 

Suggesting a Familial Type 386 

By George E. Price, M.D., Associate Professor of Mental and 
Nervous Diseases, Jefferson Medical College, Philadelphia, Pa. 

The Technique of Abderhalden’s Pregnancy Reaction 391 

By Charles C. W. Judd, A.B., M.D. 

Seven Cases of Cervical Rib, One Simulating Aneurysm 396 

By N. Gilbert Seymour, A.B., M.D., Attending Physician to 
Gouverneur Hospital Tuberculosis Clinic and to St. George’s 
Church Tuberculosis CIns.s, New York. 

VOL. l‘!0, NO. 3. — SKrTEXlBEIl, 1913 11 



11 


CONTENTS 


The Polyneuritic Form of Acute Poliomyelitis: A Clinical and Pathologic 

Study 

By S. Leopold, M.D., Instructor in Neurology and Neuropathology, 
University of Pennsylvania. 

An Intensive Study of Insects as a Possible Etiologic Factor in Pellagra 411 
By Allan H. Jennings and W. V. King, Bureau of Entomology, 
United States Department of Agriculture, Washington, D. C. 


REVIEWS 

Surgery of the Eye: A Hand-book for Students and Practitioners By 

Ervin Tdrok, M.D., and Gerald H. Grout, M.D. 441 

Cyclopedia of American Medical Biography. By Howard A. Kelly, 

M.D 443 

Progressive Medicine. A Quarterly Digest of Advances, Discoveries, and 
Improvements in the Medical and Surgical Sciences. Edited by 
Hobart Amory Hare, M.D., assisted by Leighton F. Appleman, 

M.D 444 

The Catarrhal and Suppurative Diseases of the Accessory Sinuses of the 

Nose. By Ross Hall Skillern, M.D 445 

Insomnia: Its Causes and Treatment. By Sir James Sawyer, M.D. 440 
The Collected Works of Christian Fenger, M.D. By Ludvig Hoktoen, 

M.D 447 

Diseases of the Eye. A Manual for Students and Practitioners. By 

J. Herbert Parsons, D.Sc., M.B., B.S., F.R.C.S 447 

The Technique and Results of Radium Therapy in Malignant Disease. 

By M. Dominici, M.D., and A. A. Warden, M.D 448 


PROGRESS OF MEDICAL SCIENCE 

MEDICINE 

UNDER THE CHARGE OF 

W. S. THAYER, M.D., and ROGER S. MORRIS, M.D. 

449 

450 

450 

450 

451 

452 

452 


The Experimental Production of Typhoid Bacillus-carriers in the Rabbit 

On the Presence of Diphtheria Bacilli in the Urine 

The Excretion of Formalin in the Urine after Hexamethylenamin 

(Urotropin) 

The Excretion of Formalin in the Urine ' 

Gastric Juice in Malignant and Non-malignant Diseases of Stomach an 

Duodenum 

Amylolytic Ferments in the Urine • ' 

Effect of the Antityphoid Sei'um of Besredka upon the Course of Typ oi 
Fever 



CONTENTS 

SURGERY 

UNDER THE CHARGE OF 

J. WILLIAM WHITE, M.D., and T. TURNER THOMAS, M.D. 

Experimental Contribution to the Pathogenesis of Acute Hematogenous 

Osteomyelitis 

A New Method for the Diagnosis of Renal Tuberculosis 453 

A Note on the Surgical Treatment of Calculus in the Lower End of the 

Ureter 

Calculi in the Intraparietal Portion of the Ureter 455 

Consecutive Displacement of the Cerebral Hemisphere in the Locali- 
zation and Removal of Intracerebral Tumors and Hemorrhages 
(Apoplectic Hemorrhages and Clots) 455 


THERAPEUTICS 

UNDER THE CHARGE OF 

SAMUEL W. LAMBERT, M.D. 

The Treatment of Pernicious Anemia 456 

The Treatment of Diabetes with Rectal Injections of Sugar Solutions 456 

A New Protective Measure against Diphtheria 456 

The Therapeutic Use of Strophanthin 457 

An Attempt to Interpret Present-day Uses of Vaccines 457 

Autogenous Yaceines in the Treatment of Chronic Joint Aifections 

(Arthritis Deformans and Gonococcal Arthritis) 457 

The Diagnostic and Therapeutic Value of Intravenous Injections of 

“Arthrigonin” 45g 

The Newer Theories in the Dietetic Treatment of Diabetes Mcllitus 458 


OBSTETRICS 

UNDER THE CHARGE OF 

EDWARD P, DAVIS, A.M., M.D. 

The Immediate Treatment of Depressed Fractures of the Skull in the 

Newborn 459 

The Wassermann Reaction and Tuberculin Reaction during Pregnancy. 459 

The Immunology of Pregnancy 400 

Ileus Complicating Pregn.ancy and the Puerperal Period 461 



IV 


CONTENTS 


GYNECOLOGY 

tJNDER THE CHARGE OF 

JOHN G. CLARK, M.D. 

Treatment of Uterine Hemorrhage by the Galvanic Current .... 462 
Extirpation of the Bladder 4G3 


DERMATOLOGY 

UNDER THE CHARGE OF 

MILTON B. HARTZELL, M.D. 

The Treatment of Carcinoma of the Skin with Carbon Dioxide Snow and 

the X-rays Combined 464 

The Experimental Production of Pellagra in the Monkey 464 

A Tuberculide Resembling the Lichen Planus of Wilson 464 

Studies in the Metabolism of Some Diseases of the Skin 465 

Mycosis Fungoides Successfullj’’ Treated by Hj'podermic Injections of 

Arsenic 465 

Erythema Nodosum and Tuberculosis 465 

Multiple Pigmented Warts in Pregnancy 466 

The Treatment of Epithelioma of the Lip by the X-rays 466 


PATHOLOGY AND BACTERIOLOGY 

UNDER THE CHARGE OF 

JOHN McCRAE, M.D., M.R.C.P. 

The Action of Arsenic in the Anemic 

Experimental Myocarditis from Rheumatic Sources 

Recurrent Fever 

Transplantation of Tumors upon an Embryo .... 



THE 


AMEEICAN JOUENAI 

OF THE MEDICAL SCIENCES 

SEPTEMBER, 1913 


ORIGINAL ARTICLES 

A LOBAR FORM OF BRONCHOPNEUMONIA OF LONG DURA- 
TION, OCCURRING IN CHILDREN AND YOUNG ADULTS.^ 

By David Riesman, M.D., 

PHOFESSOn of clinical medicine in the UNIVEnSITV OP PENNSYLVANIA. 

Foe some time, possibly four or five years, I have been interested 
in a disease of the lungs which cannot be readily classified nor 
easily named. 

Case I. — ^The first case I saw was in a young girl, who came to 
the dispensary of the Polyclinic Hospital and puzzled mj'^ colleagues 
and myself by a long-continued, low fever. Week after week on 
on her visits to the clinic we noted a moderate elevation of tem- 
perature, and as she had a cough, was pale and of poor physique, 
tuberculosis was naturally suspected. But aside from failure to 
find any evidence in the sputum, the physical signs — an abundance 
of crackling rales — were strictly limited to one lower lobe, there 
being no involvement of the apices. The history did not suggest 
an unresolving lobar pneumonia, and the child, so. far as I can 
recall — the record is now lost — ^w'^as not coiifined to bed at any 
time. After a most protracted course, covering possibly two or 
three months, the girl recovered completely. 

Case II. — On September 12, 1911, I saw in my ofiice Pearl L., 
a girl, aged thirteen years, who had been coughing for two weeks. 
At the age of two years she had whooping cough, othernuse she 
had been well. Although she did not appear to be very ill, I found 
impairment of resonance over the entire left lower lobe and sharply 
limited to it. The breath sounds were harsh and of a broncho- 

' Read at tlie incetinR of the As.'ociation of American Physicians, Aloy 8. 1913. A preUminarj' 
report was made to the College of Phy.sicians of Philadclpliia on February 5, 1913. 

VOL. 14D, NO. 3. — SEITElIBEn, 1913 



314 riesman: bronchopneujionia in young adults 


vesicular character. There were also numerous crackling rales. 
The right side as well as the upper lobe of the left lung was entirely 
normal. Temperature, 99.5°; pulse, 120. Four days later the 
signs were more marked, the involvement extending from the base 
of the left lobe to a little above the middle of the left scapula, and 
from the spinal column to the postaxillary line. The impairment 
was, however, very slight, and only discoverable by careful com- 
parison of the two sides. The rales were of a coarse, moist type; 
temperature," 98.9°; pulse, 108. On her next two visits very few 
rales could be detected. On October 27, six weeks after I first saw 
her and eight weeks after the beginning of her illness, rather coarse 
rales confined entirely to the left lower lobe could still be heard. 
On November 22, no rales could be found, but as late as January 4, 
1912, four months or more after the onset of the disease, the breath 
sounds over the left base w'ere still a little harsh. I saw^ the girl 
again February 17, 1912, for some trifling condition, and at that 
time the lungs were clear. 



Fjg. 1. — Bertha M. Impairment of resonance; bronchovesicular breathing: crackling rales, 

right lower lobe. 

Case III. — ^Bertha M., aged nineteen years, a Normal School 
girl, came to see me March 31, 1911, on account of a severe coug 
from which she had suffered on and off for three months. She is 
very robust and comes of healthy stock. The cough had 
run her down,” to use her own words. Temperature, lOU. > 
pulse, 120. On examination I found impairment of resonMce over 
the right chest from the angle of the scapula to the base. Over i 



3i5 


HIESMAN; BHONCHOPNEIBiONlA IN YOUNG ADULTS 

area the vocal fremitus was a little increased. On auscultation 
over the entire lower right lobe posteriorly, laterally, and in front 
from the mammary region down, numerous crackling rales could 
be heard. The lung elsewhere was normal. ^ (Fig. 1.) The patient 
had no expectoration, the appetite was diminished, the bowels con- 
stipated. By April 8, only a few dry rales remained at the base of 
the right chest. 

Case IV.— Bernice B., aged six years, had whooping cough 
soon after birth, a mastoid operation and adenectomy at three, 
otherwise nothing except slight anemia and transient choreiform 
movements. I saAV her first on May 28, 1912. She had been cough- 
ing for some time. On June 6, 1 noted in my records: Cough very 
hard; temperature, 99.4°; harsh breathing at left base. On June 
10: Cough continues; temperature, 99.4°; slight impairment of the 
percussion note of the left lower lobe posteriorly and in the axillary 
region, with harsh breathing and a fair number of fine rales. On 
June 17 the notes state: Temperature normal; cough less severe; 
rales have nearly all disappeared. 

Case V. — Dora Y., aged thirteen years, was seen ivith Dr. 
Hofkin on June 27, 1912, the history being that she had been ill 
with a continued fever for some time; just how long I could 
not ascertain. Typhoid fever and tuberculosis had been sus- 
pected. There was no cough; no expectoration; the fever was 
moderate; at no time had the child seemed very ill. A few weeks 
before she was taken sick an uncle had died in the same house of 
lobar pneumonia. Examination of the patient, who was up and 
about, showed slight impairment of resonance over the entire 
lower right lobe posteriorly and in the axillary region. The vocal 
fremitus was not altered. On auscultation a tremendous shower 
of crackling rales, which became a little finer after coughing, 
could be heard. Inspiration was harsh and expiration somewhat 
prolonged, but not bronchial. I ventured the positive statement 
that the child did not have tuberculosis and would recover fully. 
In Septernber Dr. Hofldn wrote to me that the girl had been taken 
to Atlantic City and that he had found the lungs clear five weeks 
after our consultation, but had noted the persistence of harsh 
breathing over the formerly affected lobe. When he reexamined 
her in September not the slightest abnormality could be detected. 

Case VI. — Sarah R., a girl aged twelve years, was first seen 
October 20, 1912. For three or four weeks she had had a severe 
cough, vdth some^ expectoration. According to the mother the 
child had been subject to such attacks for several ^vinters, and when 
once started they would last throughout the cold season. The 
cough was worse at night and often disturbed the child’s sleep. 
There were^ no night-sweats. The family history was good, and as 
for the patient, aside from the winter cough, she had had nothing 
except chiekenpox at the age of two years. Examination showed 



316 EIESMAN: BRONCHOPNEUMONIA IN YOUNG ADULTS 

over the left lung posteriorlj'- a slight impairment of resonance. 
On auscultation numerous dry and some moist rales could be heard 
over the lower lobe of the left lung, behind and as far forward as 
the midaxillary region. (Fig. 2.) Nowhere else were any abnormal 
sounds to be detected. The heart was normal; the spleen not 
enlarged ; temperature, 98 ° ; pulse, 80. A few days later the patient 
had a severe stitch in the left side with a catch in breathing. Wlien 
I saw her on October 27, there was no friction sound. The resonance 
oyer the left lower lobe was still a trifle impaired; the rales had 
disappeared. 



Fig. 2. — Sarah R. Impairment of resonance; bronchovesieular breathing; crackling rales; 

left lower lobe. Posterior view. 


Case VII. — 'W. N., a colored lad, aged fourteen jmars, was sent 
to me by Dr. Watson, at the Polyclinic Hospital, on March 1 of 
this year, because, just as he was about to undergo an operation 
for enlarged tonsils, it was discovered that he had a temperature of 
100°. The boy had had diphtheria at the age of seven and frequent 
attacks of tonsillitis. He did not complain of anytliing, but after 
we had detected the physical signs about to be described he 
admitted that for a week past he had had a slight cough, without 
expectoration, and some headache. I wish I could picture to you 
the surprise of my group of postgraduate students — and niy own-— 
when upon examination we found over the lower lobe of the le 
lung many small moist rales, bronchovesieular breathing, an 
impairment of the percussion note. (Fig. 3.) There was nothing 




318 kiesjman: bronchopneumonia in young adults 

in the history, in the sjanptoms, or in the general impression that 
the boy made upon us to suggest any trouble in the lung. Had it 
not been for oim practice of making a routine examination of the 
posterior bases of the lung the trouble would surely have been 
overlooked. It is not improbable that some of the ether pneu- 
monias are preceded by just such a condition as we found in this 
boy. If that is true then it behooves us in every case before an 
operation to make a thorough examination of the back of the chest. 

The blood count gave the following results: 


Hemoglobin 88 per cent. 

Red cells 5,320,000 

Leukocytes 1G,1G0 

Differential count: 

Polymorphonuclear cells 57.4 per cent. 

Mononuclear cells 7.0 “ 

Small lymphocj’tcs 28.6 “ 

Transitional 5.4 

Eosinophiles l.G “ 


At the end of three weeks from the time he was first seen the 
boy was entirely well. 

I have cited the foregoing seven cases as typical of the disease. 
I have seen perhaps double that number. 

Pathology. There have been no autopsies and no a-ray exami- 
nations, so that the actual pathological anatomy is an inference. 
The condition is not an ordinary bronchitis : (1) because it is strictly 
unilateral, while bronchitis is generally bilateral; and (2) because 
unlike bronchitis it is accompanied by an impairment of the per- 
cussion note and by breathing of a bronchovesicular character. 
Repeated examination in my cases has shovm the physical signs 
to be quite stationary in the part first affected. Nor can the 
condition be a pleurisy; the signs remain unchanged, no fluid 
is demonstrable, the tactile fremitus is either not altered or in- 
creased, and the line of dulness follows the slant of the division 
between the lobes and has not the characteristic curve of an effusion. 
There is also practically no pain. 

It is not a lobar pneumonia of the ordinary type, for it has not 
the acute, sharp onset, nor does it at any time give the impression 
that there is eomplete consolidation of the lung. 

The view that we are dealing with a lobular or catarrhal pneu- 
monia becoming confluent and assuming a lobar distribution seems to 
me to accord best with the conditions present. While lobular pneu- 
monia in the vast majority of cases is a bilateral process, there is 
no inherent reason why it may not be unilateral. As^ the modes 
of infection in the two forms of pneumonia are not unlike; and as 
the infecting organism is generally the same, it is well within the 
law of probability that lobular pneumonia may be confined to the 
same parts of the lung as lobar pneumonia. Since we possess no 



RIESJLVN: BRONCnOPNEUMONIA IN YOUNfe ADULTS 


satisfactory explanation for the lobar distribution in the one, 
none can be demanded for a similar distribution in the other. 

In some experiments with the pneumococcus, Dr. Kolmer and 
myself, using the Lamar-Meltzer method, produced in dogs a 
pneumonia confined to a single lobe that to our minds had the 
characteristics of a spreading lobular rather than of a true lobar 
pneumonia, thus bearing a close analogy to the disease under dis- 
cussion. At best, however, the pathological differences between 
lobular pneumonia and lobar pneumonia are neither great nor 
important. 

It has not been possible to obtain sputum in many of the cases. 
When it was obtained it showed chiefly pneumococci. That the 
pneumococcus is capable of causing not only acute but also chronic 
pulmonary infections is demonstrated by the painstaking researches 
ofLeutscher. 

There is no evidence that the condition is an interstitial pneu- 
monia of the type so ably described by Dr. Jacobi,^ for it heals 
without residue — without evidence of retraction. 

The disease would not impress anyone as a manifestation of 
influenza. The cases I have seen were scattered over a considerable 
period of time. They had none of the catarrhal symptoms nor the 
prostration so characteristic of influenza. Moreover, no other 
members of the patients’ families were affected. 

The chief symptoms are cough and a moderate fever, rarely above 
101°, extending over a long period — from several weeks to three 
or four months. The cough may be harassing, but at times is 
slight, scarcely of enough moment to attract attention. There 
may be considerable expectoration or none; it may contain a little 
blood, but in my experience has never been rust-colored. The phys- 
ical signs are entirely out of proportion to the symptoms. There 
is always some dulness, which is most easily detected by a careful 
comparison of the two sides, and usually extends to the angle or 
the middle of the scapula. Rales are, as a rule, abundant, and of 
the peculiar quality best described as consonating. They are 
moist rather than dry, though both types may be found. In the 
presence of minor subjective symptoms the listener will often be 
surprised when approaching the base of the chest to find his ear 
bombarded by a chorus of exquisitely crackling sounds. The rales 
are heard best in inspiration, and are often increased by coughing. 
In the majority of cases the disease involves the lower lobe of the 
left lung, but this may be a mere coincidence, as the number of cases 
is as yet too small for a definite conclusion. Girls predominated 
among my patients. As to age, the majority were between ten and 
twenty years one was twenty-seven and one twenty-eight years. 
All the cases have ended in recovery vnthout a vestige of the 
morbid process remaining. 

’ Arch. Pcd.. January, 1903. 



320 RiEs:\Lysr: BRONcnoPNEmiONiA in young adults 

On looking, not exhaustively, through the literature I find 
nothing directly bearing upon the subject. A number of authors 
in their chapters on bronchopneumonia state that at times the 
disease is most marked in one lobe, and when confluent may simulate 
lobar pneumonia. Such types are, however, described as exception- 
ally severe, mth high fever, marked dyspnea, profound prostration, 
and great danger to life. They differ thus radically from the disease 
with which we are dealing. Beddard® speaks of a primary lobular 
pneumonia which is usually confluent and is diagnosticated as lobar. 
This, however, has a sudden onset, with high temperature and severe 
nervous symptoms; the duration is short, the pyrexia is quite 
regular and sustained, and it often ends by crisis. This, of course, 
does not correspond to our disease. West^ described three types 
of bronchopneumonia, none of which is identical with the one under 
consideration; although he recognized a secondary bronchopneu- 
monia, not, however, of lobar type, with a protracted course lasting 
three months or more. The nearest approach is found in Powell 
and Hartley’s book.® They speak of a confluent form involving 
adjacent lobes of a large portion of the lung, sometimes a whole 
lobe, producing more or less dense consolidation. It may be asso- 
ciated with ordinary broncliitis of catarrhal origin, and very often 
occurs in the course of wdiooping cough. They have also met with 
it in certain cases of heart disease, and as a complication in pul- 
monary tuberculosis. In none of my cases w^as w^hooping cough, 
heart disease, or pulmonary tuberciflosis a factor in the process; 
moreover, in severity and course the condition described by Powell 
and Hartley and the one here discussed are very different. Bab- 
cock® recognizes a confluent bronchopneumonia, but does not go 
into details regarding the symptoms or course. Wilson Fox does 
not mention it. 

Treataient. In the treatment the measures that have seemed 
to me of some avail are counter-irritation to the chest, abundant 
feeding, and either a simple cough mixture wdth a small dose of 
an opiate, or one of the creosote preparations. "iMienever the 
weather was favorable I ad\nsed that the patient be taken out- 
doors. A sojourn at the seashore in proper season is also beneficial. 

The essential features of the condition I have described may 
be epitomized as follows: 

1. The disease is a confluent lobular pneumonia of lobar dis- 
tribution characterized by long duration, low fever, and the follow- 
ing physical signs: impairment of resonance, bronchovesicular 
breathing, and showers of crackling rales. 

2. It must be looked upon as one of the causes of obscure long- 
continued fever. 


* Alibutt and Rolleston’s System of ^ledicine, vol. v, Londoa, 3909. 

< Diseases of the Organs of Respiration. ^ 

5 Diseases of the Lungs, 1911, fifth edition. ® Ibid., Isew Yor , 



FOOTE: THE TKUE VALUE OF OPERATION FOR CANCER 6Zl 

3. Tlie disease always seems to end in complete recovery both 
symptomatically and anatomically. 

4. In the beginning typhoid fever may be suspected, m the later 

stages tuberculosis. 

5. The disease is, I believe, often overlooked, due to the fact 
that we seldom examine the lower posterior aspects of the chest in 
ambulatory cases, especially when the S 3 ’^mptoms are rather trivial. 
I am quite sure the diagnosis of tuberculosis is often made in these 
cases of chronic cough, with low, continued fever; but if the chest 
is carefully examined, back and front, above and below, the peculiar, 
almost specific character of the disease will be discovered, and then 
the thought of tuberculosis will be no longer entertained. 


THE TRUE VALUE OF OPERATION FOR CANCER. 

By Edward Milton Foote, M.D., 

ViaiTINO bdhoeon to the new tobk skin and cancer hospitae. 


In order to estimate the true value of operation for cancer, we 
must know (1) the object of the operation, and (2) its result. It 
is often assumed that there is onlj^ one reason for such an opera- 
tion — namely, the removal of all diseased tissue. This is the 
so-called radical operation. Its range has been extended to in- 
clude not only the visibly diseased tissues, but also those tissues 
which maj'- have in them seeds of disease for future development, 
and especiallj'' adjacent Ij^ph glands and fascial planes. This 
side of the subject has been thoroughly studied and its technical 
applications to the various cancer sites of the body repeatedl^^ 
described. In fact, it may justly be said to have dominated the 
surgical mind, determining the t 3 q>e of operation and classifying 
the results. Important as attempted removal of the cancerous 
and precaneerous tissues may be, this is bj’^ no means the onlj'- 
reason for operation in cancer, and it is manifestly" an absurdity 
to follow blindly methods of technique worked out for a radical 
operation when the possibility of radical operation does not exist. 
Rather should one shape the operation in each case to the objects 
to be gained by operation in that particular case. 

Speaking broadly, there are four reasons for operation for cancer 
which may be present in the mind of patient or surgeon: 

1. The complete removal of the cancer and cancer-bearing 
tissue — the so-called radical cure. 

2. The establishment of a diagnosis. 

3. The relief of some special sy^mptom, such as hemorrhage or 
discharge from an ulcerating surface, or the closure of a sinus, or 
the division of a stricture, or the removal of a disfigurement. 



322 FOOTE: THE TRUE ViULUE OF OPERATION FOR CANCER 

4. The attainment of certain social ends — to keep up the 
patient’s hope or to satisfy the family that something is being 
done^ etc. 

One is tempted to add another reason, which probably exists 
in the mind of the patient and his friends oftener than they would 
like to admit, and that is the possibility that the patient may die 
from operation. But if this is admitted as a reason for operation, 
it will take its place among the social ends in class four. 

It is obvious that the choice of operation should depend in 
no small degree upon which of these four reasons exists. The 
first reason — namely, the possibility of a complete removal of the 
growth — ^justly outweighs all other considerations when it is 
present. In order to accomplish this end the radical operations 
have been made more and more extensive, with a corresponding 
increase in operative mortality and postoperative debility. It is 
manifest that this tendency can be carried too far, that the price 
paid for possible immunity may be too great, especially in the 
case of a tumor beyond the earliest stage. The more extensive 
the growth the more extensive must be the operation, and the 
greater will be the operative risk, while the chance of a radical 
cure grows less and less. 

The second object for which one may operate in cancer is the 
establishment of a diagnosis. If the grovrth is small it may be 
entirely removed, so that diagnosis and complete removal are 
effected at the same time. But this double object can only be 
attained satisfactorily in the case of small growths of limited 
malignancy, such as beginning epitheliomas of the skin away from 
the orifices of the body, so situated that it is practical to remove 
a fair margin of sound skin with the tumor. On the other hand 
if one removes in this way a small tumor of the breast, and it 
proves to be a commencing carcinoma and not a fibroadenoma, 
the requirements of a radical operation will not have been satisfied. 

The field of the diagnostic operation has been narrowed in 
another way. It was once believed that a small portion of a tumor 
could safely be extracted by a punch or cut out through a small 
incision and submitted to microscopic examination. Such methods 
of examination are not looked upon with favor at the present time, 
certainly not in the earlier stages of a cancer or suspected cancer. 
The examination of a small piece of tissue may give misleading 
results, especially in incipient or doubtful cases, where a wrong 
diagnosis vdll do the most harm. Furthermore, cutting or punc - 
ing through the normal tissue planes which surround a mahgnan ^ 
growth has in some cases hastened its spread into mese nev 
planes, so that this risk has to be considered in such a diagnos ic 
procedure, and it is generally conceded that patients shoul no 
be subjected to this risk unless they are beyond the possibiii y 
of a radical operation. 



rOOTE; THE TRUE VALUE OF OPERATION FOR CANCER 323 


Another and better form of diagnostic operation is the exposure 
of a tumor, the examination of a portion of it by frozen section, 
and the completion of operation according to the report of the 
pathologist. Here the risk is that of an added delay of ten to thirty 
minutes for the pathologic examination. In many cases this is 
negligible, and the time can be reduced to a minimum, even below 
that mentioned, with practice in good surroundings.^ Some have 
made the claim that this technique exposes the patient to a dis- 
semination of his cancer even though a radical removal is at once 
carried out. Such an extreme statement is not susceptible of 
proof and most surgeons have refused to be influenced by it. There 
are, however, limitations to the method. It should not be em- 
ployed with patients too weak to endure the necessary delay with 
safety, and the section should always be removed in such a way 
that the wound can be properly closed if further operation is decided 
against. For example, one would not be justified in removing a 
section of the wall of a possibly cancerous stomach and then leav- 
ing the patient with a fistula. No diagnosis is worth sueh a price. 
There are also two technical limitations of this diagnostic method 
which should be fully admitted. It may be impossible for the 
surgeon to select for such examination the essential part of the 
tumor. There are instances in which dozens of sections have been 
made through inflammatory or other non-malignant tissue before 
the cancer was revealed. Again, some tumors are of such a nature 
that a correct diagnosis cannot be made by a few minutes’ study 
of hastily prepared sections. Admitting all these limitations the 
method is of much real value, and is often of the greatest aid to 
the patient or his friends in deciding upon a radical operation. 

Operation for cancer which is beyond the probability of radical 
removal is a subject worthy of more careful study than it has yet 
received. For practical purposes the special reasons for operation 
suggested under classes three and four are grouped together, for 
the social reasons for operation, no matter how urgent they may 
be, are almost always dependent upon some distressing physical 
condition; so in order to meet the social requirements the opera- 
tion must be planned to relieve the physical distress. 

But what is the usual procedure when a patient comes with an 
advanced primary growth, or with a recurrence, and asks for help? 
The surgeon, according to his temperament, gives a rosy prognosis 
or a guarded one. At all events he promises to do what he can. 
Now what he does is usually to follow the technique of a radical 
operation,^ just as far as he thinks the patient’s recuperative power 
Avill permit, and then closes the wound as best he may; perhaps 
saying to himself or to an assistant, “Well, I got the most of that 
out.” 

This whole conception of operation under such circumstances 
is urong. One should rather analyze the case and adapt his pro- 



OPERATION FOR CANCER 


324 FOOTE; THE TRUE VALUE OP 

cedure to meet the difficulties which are present. There is the 
patient’s dread of his disease and the fear that it cannot be removed 
by operation. _ Any operation well performed, with suitable mental 
suggestion, will allay this fear for a time; but few patients are 
today so uneducated or so simple as to give up all their fear at the 
command of the surgeon. Only returning strength for a long 
period after an operation will give them full confidence. All the 
patients in the class we are now considering are doomed to dis- 
appointment within a year or so in respect to a complete cure. 
Hence a prompt recovery from operation and good health for as 
long a period as possible are the chief aims of the operation — not 
the removal of extensive fascial planes, which at a late date may 
become cancerous, provided the patient lives long enough. 

One cannot hope to formulate specific rules to cover the wide 
varietj'' of conditions which cases of advanced cancer present to 
the operator, but there are certain general principles which ought 
certainly to be regarded. 

1. The removal of the visible growth is desirable so far as this 
can be accomplished without sacrificing important muscles, nerves, 
etc. Although one need not feel obliged to remove so wide a 
margin of sound tissue as is the rule in the radical operation the 
natural limits of the growth should be removed with it whenever 
possible. For example, if it is attached to periosteum the perios- 
teum should be removed too.. If it infiltrates a muscle at least the 
affected part of that muscle should be removed. To cut through 
a cancerous nodule or gland and leave a half or a third of it behind 
is most unfortunate, and yet the limitations of this type of opera- 
tion sometimes compel one to do this very thing. 

2. The wound should be so shaped that it can be entirely closed. 
Skin grafts or a granulating wound are allowable in a radical opera- 
tion, whereas a partial operation, which leaves a patient with a 
cancerous ulcer which did not previously exist, must usually be 
accounted a failure. If drainage is required it should be such that 
there will be no permanent sinus whenever this can possibly be 
accomplished. 

3. Lymph glands should be removed if they are readily acces- 
sible, even if deeper ones which are known to be involved are left 
behind. Thus in some cases of carcinoma of the breast, with 
axillary glands involved in chains running up to the points where 
the vessels perforate the chest, the patient derives more benefit 
from a moderate clearing out of the axilla with preservation of 
at least a part of the pectoral muscles, and plenty of skin to close 
the wound, than she does from an extensive operation, with its 
higher mortality, longer convalescence, and limited usefulness 
of the arm. Why not let such a patient get up in five days, leave 
off bandages in ten days, and enjoy good health for a year or per- 
haps more, than to squander her potentials of happiness in an 



FOOTE: THE TRITE VALUE OP OPERATION FOR CANCER 325 

effort to reacli the unattainable? _ Let us adapt the operation to 
the conditions of the patient, or, in other words, to keep m mind 
while operating the true value of the operation for that particular 

individual. - 4 . . 

4. It is of the utmost importance to save the patient s vitality 

by making the operation short, keeping the body warm, using a 
minimum of anesthetic, and above everything eise,_ by keeping 
the loss of blood down to the smallest possible point. Such a 
patient’s blood is his capital, which if lost he can replace only in 
a slight degree. The operator who s^juanders this blood capital 
therefore does him an irreparable injury. The careful operator 
will so perform his work that in most cases within a few days the 
patient will be able to enter into such enjoyment of life as condi- 
tions permit. An operation which entails a convalescence extend- 
ing over weeks or months may be worth while if it promises even 
a chance of life prolonged for many years. If a patient has at the 
best only six months or a year of comfort before him it is obviously 
bad management to compel him to devote a quarter of that time 
to recovering from an operative shock, especially when there is 
the added fact to be reckoned with that the limit of his power to 
recover is easily exceeded. 

5. If operation is performed for a special object, such as the 
relief of a plastic defect or to reduce the size of the mouth so that 
the saliva will not escape or to close a sinus in the cheek or to 
lessen the blood supply of the cancer, it is generally wise to limit 
the operation to its particular object, resisting the temptation 
to excise a few portions of the tumor because they are easily reached. 
Such excisions, unless they are so made as to include the growing 
edge of that part of the tumor, are often worse than useless, as 
they waste the patient’s blood and do not prevent recurrence for 
a period long enough to repay him. 

6. Plastic operations involving skin which is actually in contact 
with a cancerous growth may he successfully performed, and in 
case of slowly growing tumors they are often well worth while. 
There are instances in which such patchwork frequently repeated 
has kept a patient comfortable and more or less presentable for 
years after the possibility of any radical removal was exhausted. 

7. Curettage or scraping of an ulcerating cancer is of doubtful 
efficacy. Sometimes it may be of use in checking hemorrhage 
but usually it causes a positive blood loss at the time of its per- 
formance which can ill be spared. Its bad results are more notice- 
able in the case of rapidly growing tumors, in which it may fail 
to give the patient even temporary relief 

value of operation for cancer we 
must know first the object of the operation and next its result 
This brings us to the second part of our subject. In looking oyer 
the published reports of work in this field we are again struck with 



FOOTE: THE TRUE VALUE OF OPERATION FOR CANCER 


the fact that the possibility or failure of a radical cure doininates 
the surgical mind both in performance of operation and considera- 
tion of results. One may readily admit that duration of life follow- 
ing operation and freedom from recurrence are indeed the two 
great important facts which can be readily tabulated, and about 
which there can be little difference of opinion. But to the patient, 
improved function and improved appearance are equally important 
facts, although very diflScult to tabulate or record accurately. 
The Scotch have a saying that “No man should thin his own 
turnips.” Truth would be the gainer if no man estimated his 
own operative results, and yet in most cases no one else can do so. 

In the records of these cases every endeavor has been made 
to minimize subjective opinion and to give the exact facts. The 
condition of all of the patients has been noted at the end of six 
months to make comparisons the more easy. All patients operated 
upon by the VTiter or his house surgeon in hospital and private 
practice, for real or suspected malignant disease, between April 
and October 1912, have been included in the list. The difficulty 
of keeping in touch with hospital patients is well known. By 
making almost monthly inquiry all of these, with few exceptions, 
have been followed. 

It would take too much space to give abstracts of these indi- 
vidual records, so they have been grouped, and the results in the 
various groups will be noted. 

Operations of the Radical Type. In the first group are 
included all operations in which the local growth, whether primary 
or recurrent, was apparently entirely removed. In a few cases 
the usual radical operation was somewhat modified, because of the 
strong probability that metastases existed beyond the operator’s 
reach. Such patients undoubtedly have recurrences awaiting them 
even though they may not show for months. These are the patieRts 
for whom one wishes to obtain a quick recovery from operation by 
moderating the severity of the extreme radical tjqie. 

There are 27 operations in this radical group performed upon 
25 patients, 2 of the patients having tumors on difi^erent parts 
of the body. There was no mortality from these operations. 

There were 10 operations for epithelioma of the sldn in various 
parts; 4 for epithelioma of the lower lip; 2 for epithelioma of the 
mouth; 6 for carcinoma of the breast; 1 for carcinoma of the uterus; 

3 for sarcoma of the mouth; 1 for a recurrent sarcoma of the 
shoulder. 

The condition of these patients at the end of six months as 
nearly as could be ascertained is as follows: 

Examined and found without evidence of disease, 14; reported 
by letter to be free from disease, 3; have possible recurrence, 2; 
have certain recurrence, 1; died from recurrence, 2; passed from 
observation, 3; total number of patients, 25. 



FOOTE: TflE TRUE VALUE OF OPERATION FOR CANCER '327 


Operations for Diagnosis. In the second group are placed 
6 operations performed for diagnostic purposes m conditions of 
doubtful malignancy, although 4 of the patients had had previous 
operations. One patient had been twice operated on m other 
hospitals for cancer of the mouth. The removal of necrotic bone was 
followed by subsidence of symptoms, the condition probably being 
inflammatory. One patient came with recurrent ulcers of the 
forehead, which were excised and successfully skin-grafted. They 
were probably tuberculous. One patient had a swelling of the right 
hip nine years after removal of the right kidney for sarcoma. A 
lymph gland was removed and found normal. Tissue previously 
removed in another hospital by a deep incision into the hip had 
also been found to be normal. Examination with the a-rays was 
negative, yet malignancy must have existed, for the patient’s 
pain and emaciation continued, and she died in about four months. 
The fourth patient had a leukoplakia of the tongue, a section of 
which was found to be merely papilloma. The fifth patient had 
a painful swelling of the posterior part of the lower jaw, variously 
diagnosticated, and which was operated on three times before the 
swelling and pain and discharge disappeared. It was possibly an 
aberrant wisdom tooth. The sixth patient, married, aged thirty-six 
years, had a painless, fluctuating tumor of the breast for ten months. 
It was about one and one-half inehes in diameter and eontained 
purulent fluid. A section of its wall showed it to be inflammatory. 
All of these patients recovered promptly from the slight opera- 
tions, the wounds of the second, third, and fourth healing primarily, 
and those of the others by granulation. 

Their condition at the end of six months was as follows: 

Well, no sign of cancer, 2; well, after another operation which 
failed to reveal cancer, 2; died, probably from undiscovered cancer, 
1 ; passed from observation, 1 ; total, 6 cases. 

Operations for Special Objects. In the third group are 
included the operations performed for some special object upon 
patients whose apparent tumor or tumors coidd not be entirely 
removed. While the social and physical reasons for operation 
should both be considered in deciding for or against an operation, 
and in determining the nature of such operation, they so often 
coexist that it is quite impractical to separate these patients into 
two classes. 


There was no operative mortality among the 24 patients of 
this group, as there ought not to be. One is justified perhaps in 
tekmg extreme risks in the attempt to accomplish a radical cure, 
ihere is not much excuse for sacrificing a patient’s life in the 
attempt to give him temporary relief. 'l^Tile making all allowance 
for unkmown weakness of. a patient’s organs, and unforeseen acci- 
dents dmmg operation, it is still true that the operative mortality 
n this tjqie of operating can be kept near the zero mark if the 



FOOTE; THE TRUE VALUE OF OPERATION FOR CANCER 


surgeon carefully estimates the patient^s power of resistance 
before operation and adheres to his resolve not to go beyond this 
point. 

Ten of these patients had grovdhs situated in or connected 
with the mouth. Only one of these was primary^ the others were 
local recurrences, following one, two, or three operations. The 
object of operation in these cases was the removal of a painful 
or ulcerating tumor or to close a defect in the mouth. The periods 
of time through which such ends were accomplished and main- 
tained, if expressed in months, would be 0, 1.5, 2, 2, 3, 4, 4, 5' 6, 
an average of not quite three months of comfort per patient. 
This is not the duration of life, but the period during which the 
patient could fairly be said to be in a distinctly better condition 
locally than before the operation. Five of the 10 patients died; 
1 at two months from a more extensive operation performed else- 
where; 2 from recurrence in three months; and 2 from recurrence 
in four months. The remaining 5 were living at the end of six 
months, but, as stated above, only 1 of them was in a better 
condition than before his operation. 

In 3 cases a recurrent tumor was situated in the antrum and 
orbit. One of these patients was in good condition for about four 
months. Then his pain recurred, and at the end of five months 
he was operated upon by another surgeon and died in three days. 
The other 2 patients received little or no benefit from operation, 
and both died in six weeks from extension of the disease. 

In 2 cases recurrent tumors were situated in the neck and were 
very extensive. There was a partial removal in 1 case and an 
arterial ligation in the other. The first patient received very 
little benefit and died from an extension of the growth in less than 
two months. In the other case the deeper part of the growth seemed 
checked, but the superficial ulceration continued until it reached 
from ear to ear across the front of the neck. The patient was in 
good general health at the end of four months, but on account 
of the ulceration it is only fair to credit the operation with two 
months of improvement. 

A recurrent epithelioma of the scalp, involving the skull, was 
widely excised, with the periosteum under the whole area of diseased 
scalp and a smaller portion of the skull. The wound granulated 
well, but the patient’s headaches were not entirely relieved. 
In four months an additional amount of skull was removed, to- 
gether with the dura mater, which the growth had penetmted. 
The patient again recovered promptly from operation, but head- 
aches continued. He gained in health for a short time and then 
began to lose. At the end of six months he was somewhat anemic 
and had an almost constant pain. Three months of improvemen 
is as much as can be credited to his first operation. ^ 

In one ease of mixed-celled sarcoma in the parotid region, recur 



FOOTE: THE TETJE VALUE 


OF OPERATION FOR CANCER 329 


rent after two operations, a great mass of tumor tissue was removed, 
but it was found impossible to remove the growing edge of the 
tumor anywiicro in the deeper portion. Consequently u rapid 
recurrence took place, so that although the wound healed primarily , 
local improvement could scarcely be said to have exceeded one 
month. The later history of this patient is unknown. 

In 2 cases a painful recurrent breast tumor was removed from 
the wall of the chest and the wound covered with a flap of skin, 
taken in 1 case from the opposite breast. The wounds healed 
primarily, and the patients were in better local condition than 
before the operation, for periods of two months and four months 
respectively. 

An extensive carcinoma of the vulva and groin was excised. 
Glandular involvement had already extended to the retroperitoneal 
and iliac and lumbar glands at the time of operation. Both wounds 
healed promptly, and although the external appearance was good 
for two months, pain and anemia progressed with scarcely any 
interruption, and the patient died in four months, with practically 
no benefit from operation. 

A man with recurrent epithelioma of the perineum which extended 
into the deeper part of the pelvis beyond the ischium, too far for 
its safe removal, healed primarily and left the hospital entirely 
free from pain. In three months it was necessary to repeat the 
operation on account of a fresh recurrence, and this time the relief 
was of shorter duration. The patient wrote at the end of six 
months that at times he was suffering intensely. Two months 
is a fair estimate of the period of improvement attributable to 
the first operation in this case. 

Two patients with extensive carcinoma of the uterus were 
treated by ligation of the internal iliac arteries. These patients 
had not been operated upon previously. In each case the abdom- 
inal wound healed primarily, and there was less hemorrhage and 
discharge than before the operation. Pain and' .emaciation con- 
tinued in one case to such an extent that the operation had little 
more than a social value, although the patient was still able to 
get about at the end of six months. The other patient has been 
lost sight of. 


One patient with extensive abdominal carcinoma was operated 
upon to satisfy the family. The growth was so widely disseminated 
that nothing could be removed. This patient died suddenly in 
about three weeks, possibly from embolism. There was no im- 
provement from this operation. 

The summary of these operations for special objects performed 
upon 24 patients shows: 

Mortality from operation, 0; average period of improved health 
attributable to operation, two months; number of patients living ' 

^ number of patients dying in less than six 

months, 11; number of patients lost sight of, 2. 



330 ^ KING, mills: therapeutic artificial pnetoiothorax 

An average gain of two months of improved health, may seem 
to some hardly worth striving for, but this is rarely the attitude 
of the patients. They are not only most grateful for any relief, 
but many of them take great pride in even temporary victory in 
a fight in which they know they must ultimately lose. 

In conclusion it may be said that not every patient with a recur- 
rence should be operated upon. There should be some special 
object to be obtained by such operation. The operation should 
be shaped to meet such special object, and should not be patterned 
after the radical operation. All patients who have been operated 
upon for cancer should be followed month by month, and single 
recurrences favorably situated should be promptly removed. 


THERAPEUTIC ARTIFICIAL PNEUMOTHORAX.* 
By Herbert Maxon King, M.D., 

FHYSICIAK IN CHIEF. 

ANP 

Charles Wilson Mills, M.D., 

ASSOCIATE PHTSICIAN TO TBE LOOMIS SAKATOnlUM, LlBEnTY, KEW VOUK, 


The employment of pneumothorax, artificially induced, for 
therapeutic purposes was attempted at Loomis Sanatorium first 
in 1898, following the plan devised by Murphy. But few cases 
were so treated, however, and as the results were not such as to 
encourage a continuance of the method it was promptly abandoned. 
More recently the published reports of the satisfactory results 
attained by Forlanini, Brauer, Spengler, Saugman, and others 
in Europe, and Robinson and Floyd in this country, threw a much 
more encouraging light upon the procedure, and induced us to 
consider its rea'doption as a remedial measure in certain selected 
cases. 

The beneficial effects of immobilization of an actively diseased 
lung as the result of a serous effusion into the pleura have long been 
recognized, and it has been our practice at Loomis Sanatorium 
not to aspirate in such cases unless pressure symptoms compelled 
us to do so, and then only to such an extent as would relieve the 
embarrassment, and to regard with satisfaction the occurrence of 
hydrothorax whenever it appeared on the affected side in the 
presence of an active and progressive lesion. 

'When it became apparent therefore that by means of an improved 
technique immobilization and compression of the diseased lung 

1 Presented in abstract at the Mid-Trinter Meeting of the American Sanatorium Association 
at the Montefiore Sanatorium, Bedford Hills, New York, December 7, 1912. 



KING, mills: therapeutic artificial pneumothorax 331 


could be effected without serious danger to the patient, and with 
some promise of symptomatic relief, or even permanent benent, 
in advanced and progressive cases, we determined to employ the 
procedure, but, for the time at least, to limit its employment to 
this unfortunate class and not to attempt’ it until the more con- 
servative measures had failed. So far we have adhered to this 
practice, and have limited the treatment to such cases only as 
presented evidence of progressive disease in one lung and a_ com- 
paratively slight lesion in the other, and where the prognosis has 
been unfavorable. This principle has governed our selection of 
cases for treatment at Loomis Sanatorium. For that matter, 
however, our rules for the selection of suitable cases are those 
generally followed. 

A few enthusiastic advocates of the method have advised the 
procedure in early favorable cases, and have reported excellent 
results in such cases. But as the prognosis in this class is favor- 
able for arrest under the ordinary dietetic hygienic treatment, 
the additional advantages of an artificially induced pneumo- 
thorax are questionable. The procedure is a radical one in any 
case, and while it is justifiable in those who have progressed 
unfavorably despite treatment by the ordinary methods, and in 
whom the prognosis is undoubtedly bad, we have felt that in the 
present state of our knowledge it should be limited to this class. 

Selection of Cases. Forlanini considers the folloiving as indi- 
cations for treatment by induced pneumothorax: 

1. Uncomplicated unilateral phthisis, with sjow or subacute 
course, and with a pleura free from adhesions, regardless of the 
degree of the lesion. 

2. The same with such adhesions as may be removed by artificial 
pneumothorax. 

3. Bilateral phthisis not running an acute course and with lesions 
on both sides not far advanced. 


Claude Lillingston regards as favorable for treatment: 

1. Cases of extensive and acute disease of one lung coupled with 
slight or no disease of the other lung. 

2. Certain cases failing to respond to ordinary methods even 
with considerable disease of the better lung.^ 

Herbert Rhodes^ advocates the treatment in cases of 

1. Pulmonary tuberculosis limited almost if not entirely to one 
lung. 


2. Recurrent hemoptyses if at all severe. 

3. Continued fever, cough, and general increase of disease on 
one side while the other lung is healing or only slightly affected. 

Volhard,^^ admitting that the first essential is the absence of 
large adhesions in the pleura, states that only an actual trial is 


* lancet, July 15, 1911, 

* Munch, med. Woch., August 6, 1912. 


• British Med. four., October 28, 1911. 



ICING, mills: therapeutic artificial pneumothorax 


capable of establishing the presence of such adhesions, and that 
physical signs and .T-rays are of little value in determining this 
point. He considers that, so far as possible, the disease should be 
confined to one side though it may embrace the entire lung. The 
most suitable cases are those of unilateral cavities. Cases of case- 
ous pneumonia” are questionable. Severe hemoptyses may often 
be controlled. Abscess of the lung and miliary tuberculosis are 
not suitable. (Our experience in Case XII bears out this view 
with regard to abscess.) Severe cases of bronchiectasis are suit- 
able, but require long continuance of treatment. 

Klemperer® in a paper on the subject advocates artificial pneumo- 
thorax in every case with continuous fever and much expectora- 
tion, when the condition is not too desperate, although he naturally 
considers unilateral cases most favorable. He does not advocate 
the procedure in earlj^ and otherwise favorable cases. 

Almost all writers on the subject agree that slight or moderate 
laryngeal complications not only do not contraindicate the treat- 
ment, but are usually markedly benefited thereby, and a few report ■ 
good results in tuberculous complications of the intestinal tract. 

Robinson and Floyd,® regard as most suitable for compression 
therapy such cases as present unilateral disease, but do not con- 
sider as contra-indications slight and comparatively inactive lesions 
on the opposite side. 

With regard to first-stage cases, these authors argue — ^vdth what 
seems to us excellent judgment — that because in such cases pneumo- 
thorax can be readily established it is by no means proof that it 
should be, and that there is no reason to believe that pneumo- 
thorax therapy should be substituted when suitable institution 
or home treatment can be conducted. 

Among the 102 cases reported by Brauer and Spengler'^ many 
of the good results occurred in bilateral cases. 

Paradoxical as it appears, notwithstanding the increased mobili- 
zation of the untreated lung improvement in the lesion on that 
side seems often to occur simultaneously with the improvement in 
the other lung, which is being treated bj'- immobilization, although 
this does not always follow, as evidenced in Case VII of our series. 

The most plausible explanation of this fact and that most gener- 
ally accepted is that the improved condition and heightened resist- 
ance resulting from the reduced toxemia after successful compression 
place the patient in a much better condition for coping with the 
situation in the untreated lung. 

In our series all of the tuberculous cases have been “far advanced 
and bilateral, but in almost every instance the disease has been 
slight and comparatively inactive on the untreated side. 

® Berl. klin. Woch,. December 18, 1911. 

« Arch. Int. Med., April 15, 1912. 

' Beitr, z, Klin. d. Tuberk., i911, xxx. 



KING, mills: therapeutic ARTIFICIAL PNEUMOTHORAX 333 

Technique and, Apparatus. In none of our cases have we 
employed the open method of Brauer, although we realize that 
under certain conditions this method might be safer and more 
expedient, especially with beginners. But as we have so far met 
with no serious mishaps with the Forlanini puncture method, and 
as it is much easier to gain the patient s consent to this procedure, 
our experience is limited to this method. 

When we decided to reintroduce artificial pneumothorax at 
Loomis Sanatorium we asked Doctor Cleaveland Floyd to come 
and demonstrate the technique and apparatus employed by Doctor 
Samuel Robinson and himself in their work.® To this Doctor 
Floyd kindly consented, and the first injections were made by him 
in July, 1911. Five patients were selected as apparently suitable 
cases (Cases I, III, IV, XI, and XIII of our series) . He brought with 
him the apparatus devised by Robinson, and Floyd needles, which 
he has modified from those used by Brauer, together with sufficient 
nitrogen for the first injections. Subsequently, and for several 
months until we were able to obtain a Robinson apparatus and 
the Floyd needles, we improvised a home-made apparatus with 
common aspirating needles, which answered the purpose, and 
as we were unable to obtain nitrogen at that time we used atmos- 
pheric air with apparently satisfactory results, except for the 
necessity of more frequent injections. From the start we have 
used a water manometer, which is very delicate and quite satis- 
factory except in cases with decided negative pressure, when it is 
sometimes awkward by reason of its delicacy, 

Spengler employs a double manometer — one with a water column 
and the other with a mercury column, the latter to be used in cases 
with more pronounced negative pressure. This arrangement is 
obviously very convenient and time-saving. 

In the selection of a site for the initial puncture we have been 
governed entirely by physical signs, avoiding proximity to cavity 
areas, as indicated by auscultation, and endeavoring to select a 
point where resonance on percussion and auscultatory signs indicate 
some respiratory activity and freedom from adhesions. In the 
main we have kept to the anterior and posterior axillary lines, but 
occasionally have made injection through the anterior chest wall 
as high as the fourth interspace and posteriorly to the angle of the 
scapula. The choice of site has been governed by convenience in 
each case. This settled the patient is given a hypodermic injection 
01 morphine, yit to grain, and presently is placed upon the side 
opposite to that which is to be injected, with a pillow beneath to 
effect the greater separation of the ribs. The area seleeted for the 
puncture is painted with tincture of iodine. The parts are then 


^ by Robinson and Floyd in Trans. Amor. Clim. 
ASSOC., 1911, and Arch. Inter. Med., April 15, 1912. 



334 KING, mills: therapeutic artificial pneumothorax 

anesthetized with a 1 per cent, solution of novocaine injected 
slowly at first beneath the sldn, then deeper, and finally a small 
amount into the pleural sac, when by the sensation of suddenly 
released resistance the point of the needle is believed to have 
passed the parietal pleura. It is seldom necessary to freeze the 
surface with ethyl-chloride, and patients very seldom complain 
of^ pain as the result of the introduction of the needle if a few 
minutes are allowed after the novocaine injection before proceeding. 

We have customarily made a small incision through the skin 
with a sharp scalpel before introducing the pneumothorax needle, 
to avoid the pressure otherwise necessary to force the point of the 
large needle through the skin. The latter, with the stylet in place 
and the branch connecting with the manometer and nitrogen reser- 
voir shut off by the valve-cock, is now introduced, preferably at 
a slight angle to avoid injuring the visceral pleura. The same 
sense of release of resistance, but more marked, that one notices 
in the preliminary injection of novocaine, generallj’’ indicates the 
puncture of the parietal pleura. The stylet is then withdrawn and 
the valve of the stylet tube closed. The branch valve is then cau- 
tiously opened and the movements in the water or mercury column 
in the manometer observed. The valve in the tube connecting 
with the nitrogen reservoir is, of course, closed. If the point of the 
needle in the pleural sac is not plugged and there are no extensive 
adhesions at this point, the manometer will indicate a more or less 
pronounced negative pressure with oscillations corresponding to 
the respiratory movements. 

In the presence of extensive adhesions there will be little or no 
negative pressure or oscillations, while if the point of the needle 
has pierced the lung and is in communication with a bronchus 
there will be no sustained negative pressure, but oscillations may be 
quite as pronounced as when the point of the needle is in the pleura. 
Oscillations alone, therefore, do not necessarily indicate that one 
is between the pleural layers (see Case III). 

F. Pielsticker and H. Vogt® state that holding the breath by the 
patient readily shows on the manometer whether we are in the 
pleural sac or not. This does not appear to us to be a fact, however, 
for if the point of the needle is in communication with a bronchus 
and the patient holds his breath with the glottis closed a positive 
manometer reading may be registered just as it may when the 
point of the needle is between the pleural layers. In short, we have 
felt that a more or less pronounced negative pressure, with respi- 
ratory oscillations, are the only safe indications for the introduction 
of the gas. 

When these indications are met we may safely assume tJiat we 
are in the pleural sac. The manometer valve is then closed and the 


» Monatsaohrift f. Kmderheilkunde, Leipsic. 



KING, mills: therapeutic artificial pneumothorax 335 

gas allowed to pass into the chest. In the presence of a pronounced 
negative pressure this should be controlled by the valve, and per- 
mitted to run but slowly to avoid the shock of too rapid collapse 

°%he anfount of nitrogen wlrich may be safely injected at the 
initial puncture must, of course,^ depend upon the conditions in 
each case, but even when a negative pressure persists and no other 
contra-indications present, it is probably safer to limit the first 
injection to a few hundred cubic centimeters. Robinson and Floyd 
give as a maximum for the first injection 1000 c.c. 

Bonniger“ believes that in a strong man 2000 c.c. and in a woman 
1600 c.c. may be given at the first injection if manometer readings 
do not contraindicate. This seems to us unnecessarily heroic and 
not altogether devoid of embarrassing sequelse if not of danger. 

It is desirable, however, if possible to induce at the start a suffi- 
cient pneumothorax to give some symptomatic relief, either in 
lessened cough and expectoration or reduced fever, if for no other 
reason to encourage the patient more cheerfully to cooperate in 
subsequent treatment. But this can usually be accomplished by 
500 c.c. or 600 c.c., and such an amount rarely gives any sense of 
discomfort to the patient. In most cases, without extensive adhe- 
sions limiting the amount of the initial injection to this figure, 
there will still be a negative pressure at the end of the injection. 

Subsequent injections had best be made at intervals of not more 
than a few days until the manometer readings are neutral or slightly 
positive, and the cc-rays show as complete a lung compression as is 
possible. After this is accomplished the intervals between the 
injections are governed by symptoms— espeeially the amount and 
character of the sputum, temperature, etc., and the .T-rays. If 
atmospheric air is used the intervals will necessarily be shorter 
than when nitrogen is employed. 

More or less effusion occurs in about one-third of the published 
cases, and according to some of the German writers has an inhibitory 
influence upon the gas absorption. This has seemed to be a fact 
in our experience. 

The amount of gas injected after the initial operation is deter- 
rnined by the manometer readings and the feelings and condition 
of the patient. We have thought it neither necessary nor advisable 
to secure a marked positive intrathoracic pressure, and have been 
content with a neutral or very slightly positive manometer reading 
at the conclusion of the injection. Even this sometimes gives a 
sense ot tightness” and slight temporary discomfort, especially 
during the early stages of treatment. 

The manometer is the key to the whole situation, and is the one 
evice n nch has made artificial pneumothorax practicable as a 


Berl. fclin. Woch., AuRust 2G, 1912. 



336 KING, mills: therapeutic artificial FNEmiOTHOnAX 

therapeutic measure. The other accessories to the operation are 
more or less a matter of convenience. One may improvise an 
apparatus using a plain trocar or aspirating needle, and employ 
atmospheric air in place of nitrogen if necessity or expediency 
compel, but a manometer is an essential to the success of the 
treatment. 

The accidents which may occur in the process of inducing pneumo- 
thorax are fully described in the literature. The principal ones 
are pleural reflex, gas embolism, and surgical emphysema. With 
care and a little experience in the method they are for the most 
part avoidable, but when they do occur they are somewhat dis- 
concerting. 

In our experience we have met a mild “pleural reflex,” pleural 
“eclampsia” (Forlanini) once (Case IV). Robinson and Floyd 
believe that novocaine anesthesia of the pleural membranes obviates 
the risk of this complication, and Rhodes states that if the nitrogen 
is warmed “pleural reflex” is impossible. In our case novocaine 
was not employed and the atmospheric air which we were using 
at the time was not warmed. It is possible therefore that one or 
both omissions were responsible. 

It does not seem to us that air embolism is a serious menace if 
reasonable care is exercised and the behamor of the manometer is 
understood and closely watched. In our early experience, when 
on one occasion we injected air into the lung, which escaped through 
a bronchus (Case III), we made the mistake of relying upon the 
manometer oscillations in the absence of negative pressure, but 
had our needle point been in a bloodvessel there would have been 
no oscillations and we should not have proceeded. 

We have met with a mild and unimportant surgical emph^^sema 
about the point of puncture several times, with little or no conse- 
quent inconvenience. A more serious matter was that of Case X, 
when by reason of adhesions the nitrogen made its escape along 
the trachea and into the subcutaneous tissue of the face, neck, 
and chest on the side opposite to that injected, causing for a time 
a disconcerting dyspnea through involvement of the submucous 
tissue in the larynx. 

In the 16 cases here reported we have included 6 which proved 
inoperable by reason of adhesions. For statistical purposes these 
should be excluded, but we have included them because they have 
seemed to us in some respects instructive. We have classified 
our cases on a basis of results attained, and they are not arranged 
in sequence as to point of time. ^ 

Of the 10 operable cases, as is shown in the summary, 2 have 
shown marked and apparently permanent improvement; 7 have 
shown temporary improvement and more or less sjanptomatic 
relief, while in 1 case of lung abscess no improvement was observ- 
able. As has been stated our cases have all been far advanced, 



KING, mills: therapeutic artificial pneumothorax 337 

active, and bilateral, with decidedly unfavorable prognoses, a 
fact which should be borne in mind when considering the results 

attained. , • . x- u 

Since October, 1912, we have been controlling the injections by 

means of the .T-rays. Some of these plates are reproduced. 

We look upon the method with more confidence as we proceed 
and in our later cases — ^too recently placed under treatment to 
justify report at this time— we feel encouraged to hope for better 
results than it is possible to report in the present series. In any 
case there is no small satisfaction in the consciousness that we 
possess a means by which we can offer another chance of life, 
slender though it may be, to this forlorn class of otherwise hope- 
less invalids. 

Case I. — ^J. P. C., male, aged twenty-two years. Admitted 
April 15, 1911. Condition: far advanced. Turban hi (R iii- 
L i). Duration of disease: since September, 1910 (ten months). 

Symptoms. Since admission in April has had persistent hectic 
fever (98° to 99° in A.M., 101° to 104° in p.m. Pulse,^ 100 to 120. 
No normal days since admission) Cough ; expectoration averaged 
from 140 to 190 grams per day. Continued loss of weight; 4,15 
kg. since admission. Patient on absolute rest in bed. 

Physical Signs. Extensive involvement of whole right lung, 
with excavation of most of the upper lobe. Slight infiltration 
scattered throughout left lung, mostly at root. On account of 
extensive rapidly progressing destructive lesions and of severe 
constitutional disturbance this case was regarded as almost hope- 
less — in fact, practically moribund. 

July 30. First injection of 750 c.c. of nitrogen without difficulty. 
Evidently slight if any adhesions. Marked immediate improve- 
ment; temperature falling to normal on the following day and 
remaining there subsequent! Expectoration dropped from 160 
on the day of operation to 65 grams on two succeeding days, then 
rose again to from 120 to 160 grams. 

August 8 to September 14. Three injections of air, each of about 
1000 c.c. Marked continued improvement. 

^ October 15. Signs of fluid have replaced pneumothorax signs 
in right chest. Injections therefore discontinued. 

January 18, 1913. Up to the present date patient has made 
steady iinprovement. He is now walking three or four hours a 
day, and his weight has increased from 42.75 kg. at time of first 
injection to 63.52 kg., a gam of 20.77 kg. (45 pounds). The 
expector^ion still remains rather high, averaging about 90 grams 
a daj . Tubercle bacilli have been very few since establishment of 

^ and sputum 

^ sometimes have been negative for several months in 
succession* 

“ In this article all temperatures are recorded from rectal observations. 



338 KING, mills: therapeutic artificial PNEmiOTHORAX 


Physical examination and a:-ray plate indicate a markedly fibroid 
contracted right lung with pleural thickening, and a resultant 
retraction of chest walls, diaphragm, and heart. Left side clear 
(s^ee Fig. 1). 



_ •»- 1, oQ 1Q19 mioTTs marked cootraction of right lung r\ith 

Slight infiltration at left apex and root. 

on injection of pleural cavity. ^ vpars Admitted 

TT A A male, aged nineteen jears. 

September'a, 1912.' Condition: far advanced. Turban m ( m- 

Ler, expectoration averaging 

“SS "on 

of right lung; most marked in upper lobe, blig 
tion in left upper lobe. 



KING, mills: therapeutic artificial pneumothorax 


October 16. First injection of 800 c.c. nitrogen without difficulty. 
Pressure still negative at end. Temperature, which had been 100° 
or slightly over every afternoon, on second day after operation 
became normal and remained there. 

Oetober 22. 700 c.c. injected. Continued normal temperature- 
expectoration falling steadily. Patient was started on five minutes’ 
walking, twice a day, gradually increased. 



Fig. 2 —Case II. November 12 1912 


intervals of one to present at 

Improvement has continued uffintmunted P 

labor squad, working three nr fm, , Patient is on manual 

com™ed^I.^ovem»t 

June 6, ion. Co„di«;;„“t';£ *"‘y-four ^ Admitted 
Burnt, on of disease: sinee 19^1?™^) " 


340 KING, mLLS: THERAPEUTIC ARTIFICIAL PNEmiOTHORAX 

Sym'pioms. Remittent fever, 99° to 101° most of the time since 
admission. Pulse, 68 to 90. Cough; expectoration averaging 
ri2 grams in June and 128 grams in July, the month previous to 
first injection. Patient at rest in bed. 

Physical Sigiis. Indicate extensive long-standing involvement 
of the right lung, with probable cavity in the upper lobe; much 
less marked infiltration in the upper lobe of the left lung. 

Complication, Slight grade of nephritis, without enlargement 
of heart. Rather persistent extrasystole of heart beat, occurring 
usually about every six beats. • 

July 30. First injection of 700 c.c. of nitrogen in the right pleural 
sac. Apparently no adhesions. Following the injection sputum 
weight fell slightly for a few daj^s, from 145 to 106 grams., then 
rose to 150 grams again. No change in fever. 

August 8 to September 2. Four injections of air from 1000 to 
2000 c.c. each made. Some improvement dn condition shown by 
normal temperature and lower sputum weight (70 grams per day). 

September 19. An attempt was made at injection, in several 
places, but impossible to get manometer reading showing needle 
in pleural sac. Needle probably entered lung, as on the following 
day there was about a dram of blood in sputum. Physical exami- 
nation showed dulness in the lower part of the right chest, with 
very deficient breath sounds. Expectoration, however, remained 
at comparatively low figure, and exercise was gradually increased 
to thirty minutes, twice a day. Had also gained about 4.5 kg. of 
weight. 

October 27. Another attempt was made at injection. Oscilla- 
tions obtained on manometer, but no negative pressure. Needle 
was supposedly in pleural sac, and 2000 c.c. of air were injected. 
No change in manometer reading, and no evidence from physical 
signs of any resulting pneumothorax. Therefore conclusion was 
reached that the point of the needle must have passed through 
the adherent pleura into the lung, and that injected air passed 
out through the bronchi. Further attempts at injection were 
abandoned. 

Patient’s condition continued about the same until Februarj^, 
1912, when severe hemoptysis occurred. After this his condition 
became gradually worse until discharged from the Sanatorium, 

May 24. ^ ... m,* 

SuinTnavy. Temporary improvement followed injections. Inis 

ease illustrates the danger of allowing too long a time to intervene 
between injections, unless condition of compression of lung is care- 
fully controlled by physical examination or better by .T-ray 
Undoubtedly between the injections of September 2 and t e 
attempt at injection on September 19, an interval of sewn een 
days, the air had become absorbed and the pleural surfaces adlierent 

This case illustrates also the inadvisability of proceeding vi 



' KING, mills; thera-peltic A-RTIficial pneumothorax 341 


the injections in the absence of negative pressure, as shown the 
manometer even in the presence of characteristic oscillations.^ 

Case IV.— M. J. T., male, aged thirty-two years. Admitted 
November 6, 1910. Condition; far advanced. Turban m (R in 
-L i). Duration of disease: since 1906 (five years). Chest exami- 
nation indicates: Right, extensive infiltration throughout lung, 
with excavation in upper lobe. Left, compensatory changes, 
with probably small areas of infiltration, principally at root. 

Symptoms. Fever, remittent (98° to 101°); cough; expectora- 
tion averaging over 100 grams a day. Patient at rest in bed. 

Covijylication. Toxic nephritis. 

July 30, 1911. First injection of 750 c.c. nitrogen into right 
chest. Following this there was no special change noted in symp- 
toms, except slight decrease in expectoration. 

August 8. 650 c.c. of air. Patient very nervous during opera- 
tion, and in condition verging on collapse immediately’ following. 
Results of this injection appeared to be a further slight decrease 
in expectoration and a lower temperature range. 

August 16. 400 c.c. of air. Severe collapse following operation, 
with rapid feeble pulse and loss of consciousness (“pleural reflex”). 
For this reason further injections were discontinued, 

August 25, nine days after operation, temperature became lower 
and remained practically normal except for occasional days (never 
reaching, however, 101°). Expectoration also less for several days 
after injection, running from 60 to 120 grams, but amount gradually 
increasing after discontinuance of injections. 

September 15. Severe hemoptysis, followed by death. 

Summary. Slight temporary improvement in condition following 
injections. Probably a case of “pleural reflex.” 

Case V. — I. J. A,, female, aged twenty-four years. Admitted 
September 21, 1910. Condition: far advanced. Turban iii 
(R iii-L ii). Duration of disease; since March, 1910. 

Symptoms. Almost constant daily remittent fever during the 
year follovnng admission. Temperature usually between 101° 
and 102° in the afternoon,^ Night sweats. Loss of weight, 10 kg. 
(22 pounds) since admission. Expectoration averaging between 
150 and 200 grams daily. In bed or sometimes sitting up in a chair 
for a fen hours, since admission, except for a few days in December, 
1910, when, during a period of temporary improvement, tempera- 
ture was normal and she was allowed ten minutes walk, twice a day. 
No normal daj^s since that time'. 


Physical Signs. The physical signs indicate extensive in- 
volvement of the right lung, with probable excavation in upper 
lobe. Compensatory and probably some fibroid changes in left 

November 13, 1911. Finst injection of 700 c.c. air into right 
I'Jfc ^’IP^^^^^ation fell from 220 grams on day before injec- 

140, ^ 0 . 3. — SEPTEXlBEn, 1913 - -- ■' J 


12 



342 KING, mills: therapeutic artificial pneumothorax 


tion to 105 grams on following day, remaining low for several days 
No marked effect on fever. 

November 16 to December 22. Eight injections of from 600 c.c. 
to 900 c.c. each, given at intervals of from three to seven days.' 

^ Temperature now normal, and expeetoration only 80 to 100 grams 
a day. 

March 6. ^ Injections continued at intervals of one to two weeks 
up to this time, condition remaining about the same, except for 
some tendency to increase of expectoration. Following the injec- 
tion on this date the temperature gradually rose and fever was 
present, usually about 102° in the afternoon for the following 
month. Expectoration averaged about 150 grams. For a few days 
in the early part of April temperature was normal, but then rose 
again, and fever remained until discharged from the Sanatorium 
on May 4, 1912. No further injection given during this time. At 
time of discharge examination showed signs of pneumothorax 
throughout the right chest e.xcept at the apex, and slight amount 
of fluid at base. 


Summary. This case was distinctly disappointing in results. 
A practically unilateral case, with high expectoration and probable 
cavity, it seemed to offer good indications for pneumothorax. 
But in spite of the fact that the latter was successfully established, 
and that the lung was apparently well collapsed, no permanent 
good results followed. Probably the temporary improvement in 
condition shown by reduction or absence of fever and lower expecto- 
ration may be attributed to the pneumothorax, but this improve- 
ment was only transitory. (Subsequent to discharge patient went 
to Saranac Lake, where pneumothorax has been maintained with 
apparently good results. At last report, December 1, 1912, patient 
had gained over twenty pounds, and has been feeling much better.) 

Case VI. — F. S. M., male, aged forty-five years. Admitted 
January 5, 1910. Condition: far advanced. Turban iii (R iii- 


Li). Duration: since May, 1909. 

Symptoms. Patient’s condition for first nine months after 
admission in January, 1910, was steadily progressive. Short 
periods of fever, heavj’’ expectoration, and loss of weight continued 
until patient, although six feet two inches in height, in October, 

1910, weighed only 46.05 kg. (101 pounds). Unexpectedly and 
without any decided change in treatment he at this time began 
to improve, this improvement continuing most spectacularly until 
in June, 1911, he had reached a weight of 73.3 kg. (161 pounds, 
60 pounds gain) and was on two hours’ exercise a day.^ The expecto- 
ration did not decrease materially, however, during this time, 
remaining most of the time over 100 grams a day. In the tall o 

1911, the patient began to lose ground again. A.t the time or 
first injection, January 30, 1912, he weighed 65.5 kg. (144 poun s), 
was -swthout fever, and had an expectoration of lU grams a ay. 



KING , mills: therapeutic artificial pneumothorax 343 


Physical signs at the time of injection indicated an extenshm 
involvement of right lung with probable excavation in upper lobe. 
Compensatory signs in left lung, with slight infiltration of upper 

January 30. First injection of 400 c.c., of air.^ Pronounced nega- 
tive pressure was obtained and marked respiratory oscillations, 
indicating absence of pleural adhesions. 

February 1. Two days later 1000 c.c. of air was in 3 ected, the 
pressure still being slightly negative at the' end of the injection. 
Patient complained of no inconvenience except a slight feeling of 
tightness through chest. 

February 7 to March 25. Four injections of about 1000 c.c. 
each. 

During this time the patient had gained a little weight (650 
grams) and felt perhaps somewhat better, but the chief effect 
of the injection had been on the amount of the expectoration, 
which had fallen from 171 grams to 103 grams per day. The signs 
indicated an extensive pneumothorax throughout lower two-thirds 
of right chest. The signs continuing it was not thought necessary 
to repeat the injections until April 23 when 1300 c.c. of nitrogen 
was injected. 

During May the expectoration fell to 65 grams, by far the lowest 
that it had been at any time since his admission. He was, however, 
losing weight again at this time. 

June 14 to July 20. Three injections of 600, 950, and 1200 c.c. 

During June and July, although there was a complete collapse of 
the lung, the condition did not improve, there being a continual loss 
of weight, and the expectoration rising again from 65 to 117 grams. 

No further injections were made until September 7, the pneumo- 
thorax signs continuing. 

September 7. Attempt made at injection, but most surprisingly 
it was found impossible to obtain a negative pressure or to get 
good respiratory excursions; 250 c.c. of nitrogen were cautiously 
injected, but it was deemed inadvisable to attempt more than 
this. 


September 9. Another attempt at injection was made, wdth 
the same result. No negative pressure could be obtained, and only 
100 c.c. nitrogen were injected. 

Ao further injections have been attempted. The explanation 
of the failure to obtain a satisfactory negative pressure was not clear. 

An examination on September 21 showed that in addition to the 
pneumoWmrax there was also a small amount of fluid in the right 
chest. These signs are still present (see Fig. 3). 

Tlie patient s condition is slowl.y growing worse. The expecto- 
ration has risen again to 151 grams, and the loss of weight has 



344 


king, mills: therapeutic artificial pneumothorax 


Summary. Temporary improvement. Disappointing ease in 



Fig. 3. — Case VI. November 12, 1912. Hydropneumothorax of right chest ■with 

collapse of right lung. 


Case VII. — D,, male, aged forty-two years. Admitted 
October 1, 1911. Condition: far advanced. Turban iii. Dura- 
tion of disease: since March, 1911. 

Syinptoms. Constant fever since admission, averaging about 
98° in a.ji. and 102° in p.m. Expectoration, 70 to 80 grams a day. 
In bed since admission. 

Complications. Larjmgitis of mild grade. Dry otitis media. 
Diabetes mellitus of mild grade. On carbohj^drate restricted diet 
the urine had become and remained free of sugar. 

Physical Signs. Indicate extensive involvement of left Jung, 
with cavity signs in lower part of upper lobe. Slight infiltration 
of apex of right lung. 


KING, mills: therapeutic artificial PNEmiOTHORAX 345 


Case did not seem an especially favorable one for pneumotborax 
treatment in view of the complications and the advanced condition. 

December 8. First injection of 300 c.c. air into the leit chest. 
Temperature, which had reached 101° and over evep day since 
admission, on the day following pneumothorax, reached only 100.4 , 
rising again, however, on the succeeding days. 

December 12, 1911 to January 2, 1912. Four injections of from 
600 to 1000 c.c. each. Marked improvement in condition. ^ Tem- 
perature normal and expectoration less. Patient now sitting up 
two or three hours a day. 

January 5. Graduated exercise (walking) begun and gradually 
increased to fifteen minutes, twice a day. This was followed, 
however, by a return of fever to about 101° in the afternoon. 

January 17. 600 c.c. of air. Temperature again normal on 

following day, but immediate return of fever when exercise was 
resumed. 

January 30. 700 c.c. of air. Temperature again fell to slightly 
over 100° on the following three days, although after that it rose 
again to 101° or over, even though no further attempts at exercise 
were made. Expectoration fell to an average of about 50 grams. 

February 7. 700 c.c. of air. No improvement followed this 
injection. A few days later there was a marked exacerbation of 
fever, as high as 103° on most days, the expectoration rose and the 
general condition grew progressively worse. Although the signs of 
extensive disease and cavitj? in the left lung had at this time been 
replaced by the pneumothorax signs, yet on the right or “good” side 
there were signs of a considerable exacerbation of the disease, and 
this was held to be the reason for the increase of symptoms. Under 
these circumstances it was not deemed adiusable to continue further 


injections. The patient’s condition grew progressively worse from 
this time on and death occurred on May 27. The pneumothorax 
signs in the left chest continued until the end, although becoming 
much less extensive than immediately after the injections. During 
the last few weeks before death dyspnea was a very marked and 
distressing feature. 


Summary. Considering the condition of the patient at the time 
when the injections were first made, the improvement which fol- 
lowed, even though only temporary, was rather remarkable. The 
ultimate exacerbation of the disease on the “good” side may 
perhaps have been due to the increased compensatory activity of 
that side occasioned by the pneumothorax, though there is no real 
e\ idence leading to such a conclusion aside from the old post ergo 
yropfcr argument. Even if so it is the only case in which we have 
seen any exacerbation of the disease that could be attributed, even 
remotely, to the pneumothorax, and we feel that the contingency 
sekcte^^^^ ^ reasonably disregarded in properly 



346 KING, mills: therapeutic artificial pneumothorax 

Case VIII. R. F., male, aged eighteen years. Former Sana- 
tonum patient, resident of Liberty. Condition: far advanced. 
Turban iii (R i-L iii). Duration of disease: since 1908 (three 
years). 

Symptoms. Severe continued hemoptysis over period of several 
days. Disease rather rapidly progressing since previous summer. 
Temperature and pulse normal. 

Physical Signs. The physical signs indicate extensive involve- 
ment of the left lung, with numerous bubbling rales. No signs of 
moisture on the right. Thorough examination was not made at 
the time of injection on account of hemopt 3